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MINOR  AND  EMERGENCY 
SURGERY 


BY 

WALTER  T.  DANNREUTHER,  M.  D. 

SURGEON   TO   ST.    ELIZABETH'S   HOSPITAL   AND   TO   ST.  BARTHOLOMEW'S 

CLINIC,     NEW    YORK    CITY;     EX-HOUSE    PHYSICIAN    AND     SURGEON, 

JERSEY   CITY   HOSPITAL,    ETC. 


ILLUSTRATED 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1911 


Copyright,  igii,  by  W.  B.  Saunders  Company 


1]  2.1 


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PRINTED    IN    AMERICA 

PRESS    OF 

W.     B.     SAUNDERS     COMPANY 

PHILADELPHIA 


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THIS  BOOK  IS  DEDICATED 
TO 

the  earnest  and  ambitious  young  physician  who  is  devot- 
ing all  his  time  to  hospital  work,  and  whose  only  reward 
is  the  knowledge  and  experience  thus  gained: 

THE  HOSPITAL  INTERNE 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/minoremergencysuOOdann 


PREFACE 


Many  excellent  books  on  minor  surgery  have  been 
written  but  so  far  as  the  author  is  aware,  none  has 
been  adapted  exclusively  to  the  needs  of  the  hospital 
interne.  Each  of  the  following  pages  has  been  pre- 
pared expressly  for  the  members  of  a  resident  staff: 
for  the  interne's  guidance  when  acting  independently; 
to  assist  the  ambulance  surgeon  in  emergencies,  to 
simplify  practical  work  for  the  junior  and  to  aid  the 
senior  in  some  of  his  predicaments.  If  this  little 
volume  but  serves  this  purpose,  its  object  will 
haven  been  attained.  However,  as  the  general 
practitioner  and  even  the  specialist,  as  well  as  the 
surgeon,  is  so  frequently  called  upon  to  cope  with  this 
class  of  emergencies,  the  author  hopes  that  others 
may  find  some  useful  points  in  its  perusal. 

Many  subdivisions  and  details  of  minor  surgery 
have  been  purposely  omitted,  as  it  is  not  intended 
to  rewrite  all  that  can  be  found  elsewhere.  Also,  it 
may  seem  that  the  special  attention  accorded  some 
of  the  more  oridnary  conditions,  usually  considered 
elementaiy  and  unworthy  of  much  thought  by  the 
medical  student,  is  disproportionate  to  the  com- 
paratively small  amount  of  space  devoted  to  them 
in  the  average  text-book.  An  effort  has  been  made 
particularly  to  emphasize  those  points  that  are  of 
great  importance  in  practical  work,  but  which  are 
often  apparently  disregarded  or  ignored.     To  avoid 

13 


14 


PREFACE 


confusion  and  favor  brevity,  the  treatment  out- 
lined is  in  most  instances  that  which  experience  has 
proved  to  be  the  most  satisfactory.  Incidentally, 
this  will  accoimt  for  the  frequent  mention  of  iodine 
as  an  antiseptic  and  germicide.*  It  is  assumed  that 
the  reader  possesses  the  average  theoretical  knowl- 
edge of  the  medical  graduate,  but  has  had  little  or 
no  practical  experience,  and  therefore  the  author 
has  endeavored  to  make  his  statements  as  simple, 
clear  and  concise  as  possible. 

Due  acknowledgment  is  made  for  information 
derived  from  many  sources;  the  standard  medical 
journals  and  text-books  have  been  freely  consulted 
and  the  methods  in  vogue  at  the  leading  hospitals 
investigated.  The  author  especially  desires  to 
express  his  thanks  and  indebtedness  to  his  friends, 
Dr.  Terry  M.  Townsend  of  New  York  and  Dr.  Frank 
D.  Gray  of  Jersey  City,  for  their  careful  considera- 
tion and  criticism  of  the  manuscript,  to  Miss  Eleanora 
Fry  for  the  painstaking  and  graphic  illustrations, 
and  to  the  publishers  for  their  uniform  kindness  and 
courtesy. 

Walter  T.  Dannreuther. 

New  York  City 
October,  191 1. 


*"The  Surgical  Value  of  Iodine,"  Medical  Record,  January  25,  1908. 
"The  Practical  Value  of  Tincture  of  Iodine  and  Iodine  Catgut  in  Major 
Surgery,"  Medical  Record,  January  16,  1909. 


CONTENTS 

Page 

Introduction i? 

CHAPTER  I. 
The  Ambulance  Surgeon 19 

CHAPTER  II. 
Accidental  Wounds 23 

CHAPTER  III. 
Traumatic  Injuries  of  Joints 48 

CHAPTER  IV. 
Simple  Fractures 64 

CHAPTER  V. 

Compound  Fractures  and  Traumatic  Amputations     .    106 

CHAPTER  VI. 
Sequels  of  Fractures 116 

CHAPTER  VII. 
Acute  Pyogenic  Infections '  .   123 

CHAPTER  VIII. 
Effects  of  Intense  Heat  and  Cold 140 

CHAPTER  IX. 
Ulcers — Bed-sores 151 

CHAPTER  X. 
Foreign  Bodies 159 

CHAPTER  XI. 
Surgical  Shock  and  Collapse — Death 168 

CHAPTER  XI I. 

Minor  Operations 180 

Index 213 

15 


MINOR  AND  EMERGENCY 
SURGERY. 


INTRODUCTION. 

Having  attained  the  coveted  degree  of  M.  D., 
the  majority  of  recent  graduates  seek  an  appoint- 
ment on  the  resident  staff  of  some  hospital.  The 
term  of  service  may  vary  from  one  to  three  years, 
usually  averaging  eighteen  months,  and  the  ex- 
perience and  knowledge  gained  during  this  time 
will  prove  to  be  of  inestimable  benefit  and  of  the 
utmost  importance  throughout  the  young  physician's 
subsequent  professional  life.  Although  he  is  af- 
forded the  opportunity  of  doing  a  certain  amount 
of  dispensary  work  in  connection  with  the  modem 
college  course,  the  comparatively  few  real  emer- 
gencies presenting  and  the  student's  subordinate  posi- 
tion greatly  minimize  the  benefits  which  apparently 
might  be  derived  therefrom.  It  is  while  serving 
as  a  member  of  a  house  staff  enjoying  an  active 
service  that  there  is  almost  imlimited  opportunity 
of  applying  the  principles  and  teachings  of  the 
college  course.  Here  too  are  encouraged  and 
developed  those  qualifications  so  essential  to  suc- 
cess in  practice:  acuity  of  perception,  dexterity 
and  self-reliance. 

The  first  few  months  of  the  hospital  service  are 
usually  devoted,  as  they  properly  should  be,  to 
2  17 


1 8  MINOR  AND  EMERGENCY  SURGERY 

laboratory  work,  history  taking,  applying  ward 
dressings  under  the  direction  of  the  house  surgeon, 
and  the  like.  This  gives  the  junior  an  opportunity 
to  feel  at  home  in  his  new  surroundings,  to  acquaint 
himself  with  the  routine  of  the  institution  and  its 
personnel  and  to  observe  more  or  less  emergency 
work  attended  by  his  superiors  before  assuming 
any  responsibilities  himself. 

The  interne  should  ever  respect  and  obey  the  advice 
and  instructions  of  the  members  of  the  visiting  staff 
and  any  criticism  that  he  has  to  make  of  their 
suggestions  should  be  entirely  mental.  Discussions 
in  private,  however,  concerning  the  diagnosis  and 
management  of  cases  are  to  be  encouraged.  The 
interne  should  keep  his  eyes  and  ears  open  and  his 
mouth  shut  when  in  the  wards.  "Errare  est 
humanum"  and  even  the  visiting  surgeons  may 
make  mistakes  occasionally,  but,  as  Dr.  Brickner 
has  so  aptly  said,  they  probably  have  better  reasons 
for  being  wrong  than  the  interne  has  for  being  right. 

Each  member  of  the  house  staff  should  do  his 
share  toward  the  maintenance  of  a  harmonious 
atmosphere  among  his  fellows:  routine  duties  being 
performed  willingly  and  cheerfully  and  favors 
exchanged  whenever  possible.  Mutual  kindness, 
courtesy  and  loyalty  will  promote  good  feeling  and 
make  the  day's  work  more  pleasant. 

The  interne  should  never  forget  his  dignity  in 
the  presence  of  nurses  and  orderlies.  They  should 
be  shown  every  consideration  but  allowed  no  liber- 
ties or  undue  familiarity.  Regardless  of  the  ap- 
parent provocation,  subordinates  should  never  be 
criticised  or  corrected  except  in  private. 


CHAPTER  I. 
THE  AMBULANCE  SURGEON. 

It  is  a  grave  error  to  permit  a  "green"  interne 
to  do  ambulance  work  immediately,  and  many 
cities  have  recognized  this  fact  by  adopting  an 
ordinance  requiring  at  least  six  months'  service  on 
the  resident  staff  before  undertaking  the  duties  of 
an  ambulance  surgeon.  He  should  at  least  transfer 
a  few  elective  cases  to  and  from  the  hospital  before 
answering  any  emergency  calls,  thereby  accustom- 
ing himself  to  the  presence  of  a  crowd.  Thus  he 
will  gradually  acquire  self-confidence  and  become 
impervious  to  the  remarks  and  audible  criticisms 
of  the  by-standers.  An  ambulance  surgeon  is  at 
first  likely  to  appear  arrogant  and  disagreeable,  or 
nervous  and  undecided,  faults  which  should  be 
studiously  overcome.  Collective  gentleness,  cour- 
tesy and  firmness  will  win  respect  and  inspire  con- 
fidence. The  public  is  quick  to  recognize  the 
surgeon's  attitude  and  will  usually  behave  accord- 
ingly. He  should  never  forget  that  he  is  a  gentle- 
man as  well  as  a  physician  and  should  conduct 
himself  as  both. 

The  patient  should  always  be  moved  as  carefully 
as  possible,  his  home  respected,  be  it  palatial  or 
humble,  and  his  relatives  and  friends  shown  every 
consideration.  The  danger  of  handling  a  patient 
roughly    cannot   be    too    strongly    emphasized,    no 

19 


20  ^         MINOR  AND  EMERGENCY  SURGERY 

matter  how  unimportant  it  may  seem  at  the  time. 
For  example,  in  transferring  a  case  of  appendicitis, 
a  sudden  jar  may  rupture  an  existing  abscess,  ulti- 
mately resulting  in  a  fatal  issue. 

Occasional  difficulty  will  be  experienced  in  trans- 
porting the  stretcher  downstairs,  b.ecause  of  acute 
angles  in  the  stairway.  Under  such  circumstances 
it  is  better  to  either  carry  the  patient  down  bodily, 
or  seat  him  in  a  chair  and  carry  the  chair  down. 
He  should  always  be  carried  feet  first  down  stairs, 
and  vice  versa.  The  greater  part  of  the  actual 
work  may  be  safely  left  to  the  driver,  policemen 
present  and  by-standers,  under  the  supervision  of 
the  surgeon.  It  is  not,  however,  correct  or  con- 
siderate to  expect  or  demand  the  assistance  of 
members  of  the  patient's  family.  It  is  well  to 
see  that  the  patient  is  completely  covered  with 
blankets;  and  covering  the  face  with  a  handkerchief 
while  placing  the  stretcher  in  the  ambulance  is  a 
trifling  attention  that  will  be  greatly  appreciated. 

The  following  hints  are  worth  remembering: 

Don't  lose  your  nerve;  keep  cool. 

Don't  lose  your  temper  under  any  circumstances. 
Rather  submit  to  insult  than  to  lower  your  dignity 
by  arguing  or  fighting  with  anyone.  Call  on  the 
police  for  aid  when  you  need  it. 

Don't  forget  that  the  patient  is  the  only  matter 
of  importance  that  concerns  you  and  that  he  requires 
all  your  attention. 

Don't  discuss  your  actions  with  by-standers. 
Decide  quickly  what  you  intend  to  do  and  do  it 
unhesitatingly. 


THE  AMBULANCE  SURGEON  21 

Don't  refuse  to  take  any  unconscious  person  to  the 
hospital,  even  though  you  are  sure  he  is  only  in- 
toxicated. It  is  better  to  have  fifty  "drunks"  in 
the  hospital  each  night  than  to  have  one  die  of  an 
unsuspected   fractured   skull  in   the  police  station. 

Don't  forget  that  the  appearance  of  a  new  am- 
bulance surgeon  is  always  productive  of  a  great 
deal  of  malingering  on  the  part  of  some  of  the  in- 
habitants of  the  neighborhood. 

Don't  do  on  the  street  that  which  can  be  done  at 
the  hospital. 

Don't  "play  to  the  galleries."  Act  quickly,  quietly 
and  decisively,  but  do  all  that  is  absolutely  necessary 
and  return  to  the  hospital  as  soon  as  possible. 

Don't  make  an  intimate  of  your  driver.  A 
friendly  spirit  is  commendable  but  anything  more 
than  that  lowers  your  profession  in  his  eyes. 

Don't  stop  to  talk  to  acquaintances  on  the  street. 
You  are  a  public  servant  while  on  duty  and  there  may 
be  another  call  awaiting  you  on  your  return  to  the 
hospital. 

Don't  allow  your  driver  to  drive  recklessly;  it 
jeopardizes  too  many  lives.  Always  get  to  the 
scene  of  an  accident  as  soon  as  possible  and  then 
adapt  the  speed  of  the  ambulance  to  the  needs  of 
the  patient. 

Don't  permit  the  driver  to  ring  his  gong  unneces- 
sarily. 

Don't  invite  your  friends  to  ride  on  the  ambulance. 
It  is  not  a  pleasure  vehicle. 

Don't  forget  that  you  cannot  take  anyone  to  the 
hospital  against  his  will  or,  if  the  patient  is  uncon- 


2  2     MINOR  AND  EMERGENCY  SURGERY 

scious  and  relatives  are  present,  without  their  consent. 
If  you  are  requested  to  take  the  patient  home  or 
to  another  institution,  and  the  distance  is  within 
reason,  do  it  cheerfully. 

Don't  fail  to  respect  a  patient's  religion,  especially 
if  he  is  a  Catholic;  a  priest  should  always  be  per- 
mitted to  administer  the  last  rites. 

Don't  forget  to  report  in  person  to  the  house 
surgeon  at  once  if  you  have  admitted  a  grave  case 
to  the  hospital. 

Don't  forget  to  change  the  linen  on  the  stretcher 
after  each  call. 

Don't  forget  to  replenish  the  appliances  carried 
in  the  ambulance  and  the  ambulance  bag  after  each 
call. 

Don't  forget  that  you  have  assumed  great  respon- 
sibilities and  that  human  life  often  depends  upon 
your  judgment  and  actions. 

If  these  suggestions  are  faithfully  followed, 
they  will  aid  the  ambulance  surgeon  in  contributing 
his  share  to  the  efficiency  of  the  service  and  thereby 
reflect  credit  upon  the  institution. 


CHAPTER  II. 


ACCIDENTAL  WOUNDS. 


Classification  of  Wounds 


I.  Contused 


Lacerated 


3.   Incised 


4.  Punctured 


5.  Poisoned 


a.  without  external  communication. 

b.  with  external  communication, 
a.  localized. 

b'.  extensive:    avulsion    of    a   limb   or   the 
scalp. 

a.  simple. 

b.  complicated:       underlying      important 
structtires  severed. 

a.  penetrating. 

b.  perforating. 

a.  pyogenic  infections. 

b.  tetanic  infections. 
■    c.    venom  infections. 

d.  rabid  infections. 

e.  chemical  infections. 


6.   Gunshot 


/  a.  blank  cartridge 


j      I.   powder  grains. 
I     2.   wadding. 


\b.  bullet. 

Wounds  are  designated  and  classified  according  to 
the  nature  of  the  causative  trauma  and  the  char- 
acter of  the  injury.  It  is  well  to  remember  that 
notwithstanding  the  apparent  localization  of  a 
wound  in  the  beginning,  sloughing  of  the  skin  and 
soft  parts  may  ensue  at  any  time  within  ten  days 
as  the  result  of  extensive  contusion,  no  evidence  of 
which  presented  at  the  first  examination.  This 
is  equally  true  of  fractures,  dislocations,  etc.     For 

23 


2  4  MINOR  AND  EMERGENCY  SURGERY 

instance,  in  crushing  injuries  the  skin  wound  ma}^ 
appear  insignificant,  yet  areas  of  the  soft  parts  may 
be  extensively  pulpified.  If  any  blood-vessels  of 
large  caliber  have  been  iniptured,  gangrene  may 
result  in  consequence  of  the  impaired  vitality  of  the 
tissues;  the  prognosis  therefore  should  always  be 
guarded.  Free  external  bleeding  or  subcutaneous 
hemorrhage  usually  accompanies  all  wounds  and  the 
presence  of  more  or  less  foreign  material  is  to  be  ex- 
pected. It  will  often  be  difficult  to  arrive  im- 
mediately at  a  definite  conclusion  regarding  the  exact 
nature  and  extent  of  the  injury,  especially  when 
dealing  with  contusions,  owing  to  the  accompanying 
swelling.  In  such  cases  it  is  better  to  err  on  the 
safe  side  and  assume  the  presence  of  a  more  severe 
injury  than  to  ignore  its  possibility.  Any  wound 
may  produce  shock  in  direct  proportion  to  its  sever- 
ity and  extent. 

Examination  of  Wounds. — ^A  careful  examination 
of  every  wound  and  a  thorough  understanding  of 
the  existing  pathology  is  absolutely  necessary  in 
order  that  remedial  measures  may  be  instituted  in- 
telligently. This,  however,  does  not  mean  to  "ex- 
amine" a  wound  by  probing  it  with  a  dirty  finger,  for 
little  knowledge  will  be  derived  in  this  manner  and 
additional  infection  may  be  introduced.  Under 
exceptional  circumstances  only,  as  when  the  presence 
of  a  foreign  body  deep  in  the  wound  is  suspected, 
is  sterile  instrumental  probing  permissible.  It  is  un- 
necessary and  inhuman  to  insist  upon  probing  a 
wound  simply  to  satisfy  curiosity  as  to  its  extent, 
as  the   possibility  always  exists  of  again  exciting 


ACCIDENTAL   WOUNDS  25 

hemorrhage  which  has  been  arrested  by  natural  pro- 
cesses, such  as  coagulation  of  the  blood  or  torsion  or 
retraction  of  the  blood-vessels.  Even  when  dealing 
with  bullet  wounds,  probing  is  of  little  value  in  locat- 
ing the  bullet  unless  very  near  the  surface,  because 
of  the  free  extravasation  of  blood  into  the  muscles 
and  other  soft  tissues  separating  the  fibers  and  creat- 
ing numerous  false  passages.  Radiography,  on  the 
contrary,  is  extremely  useful  for  the  determination 
of  the  exact  location  of  a  foreign  body.  The  possi- 
bility of  a  concomitant  fracture  at  the  site  of  the 
wound,  or  in  head  injuries  at  the  base  or  on  the  op- 
posite side  of  the  skull,  should  be  constantly  borne 
in  mind,  even  though  there  is  no  distinct  evidence  of 
fracture.  Here  again  the  :;t:-ray  will  be  a  valuable 
aid.  Enlarging  the  wound  slightly,  or  freely  if 
necessary,  will  often  greatly  facilitate  inspection. 
The  following  features  of  wounds  should  be  deter- 
mined in  order: 

1.  Extent  of  injury. 

2.  Accompanying  fracture. 

3.  Integrity  of  the  soft  structures:  periosteum, 
muscles,  tendons  and  nerves. 

4.  Foreign  material  present. 

5.  Source  of  hemorrhage. 

Treatment  of  Wounds. — The  cardinal  principle  of 
the  treatment  of  wounds  is  to  bring  about  union  by 
first  intention  if  possible.  In  many  instances  such 
an  immediately  favorable  result  is  obviously  out  of 
the  question,  and  every  effort  should  then  be  made 
to  secure  rapid  granulation  from  the  bottom.  Upon 
the  surgeon's  judgment  will  depend  whether  a  wound 


2  6  MINOR  AND  EMERGENCY  SURGERY 

shall  be  entirely  closed  or  drained  primarily.  When 
in  doubt,  wounds  opening  into  a  cavity  should  be 
drained ;  in  others  an  attempt  may  be  made  to  obtain 
primary  tmion.  If  closure  without  drainage  is  after- 
ward proved  to  be  an  error  of  judgment,  it  is  easily 
remedied  by  partial  re-opening  and  drainage.  In 
general,  the  treatment  of  wounds  consists  of : 

1.  Arrest  of  hemorrhage. 

2.  Shaving  and  cleansing  with  green  soap  of  the 
surrounding  skin. 

3.  Irrigation  of  the  wound  with  hydrogen  per- 
oxide. 

4.  Removal  of  all  extraneous  matter. 

5.  Suture  of  divided  important  structures. 

6.  Institution  of  drainage,  if  required. 

7.  Coaptation  of  the  edges. 

8.  Injection  of  tincture  of  iodine  into  the  wound. 

9.  Application    of    a    wet    gauze    dressing    and 
bandage. 

10.  Putting  the  injured  part  at  rest. 
Fortunately  there  are  many  efficient  methods  of 

arresting  hemorrhage  at  our  disposal.  In  the 
majority  of  instances  the  simple  pressure  of  a  wet 
dressing  is  sufficient  to  control  it.  If  a  bleeding 
vessel  has  been  wounded  but  not  entirely  severed, 
the  division  should  be  completed  to  permit  retrac- 
tion. When  a  single  artery  continues  to  spurt,  it 
should  be  seized  with  a  hemostatic  clamp,  but 
care  should  be  taken  that  the  jaws  grasp  the  vessel 
only  and  do  not  include  any  adjacent  tissue.  It 
may  then  be  subsequently  ligated  with  catgut,  if 
necessary.     In    severe    injuries    with    considerable 


ACCIDENTAL  WOUNDS  27 

arterial  hemorrhage  the  tourniquet  is  of  inestimable 
value  and  should  be  applied  as  near  to  the  injured 
region  as  is  consistent,  in  order  to  devitalize  as  little 
healthy  tissue  as  possible.  If  a  i-ubber  tube  or 
strap  is  not  at  hand,  a  tourniquet  may  be  improvised 
by  twisting  a  stick  in  a  knotted  rope  or  strip  of  linen. 
The  use  of  the  tourniquet  should  be  avoided  in  pa- 
tients with  atheromatous  arteries.  Plugging  a  wound 
of  the  chest  with  cotton  will  effectually  control  hem- 
orrhage from  an  intercostal  artery.  The  actual 
cautery  is  rarely  required  to  stop  hemorrhage  from 
a  wound,  except  in  the  presence  of  persistent  oozing, 
as  in  injuries  of  the  liver  or  spleen.  Styptics  are 
useless  in  the  treatment  of  surgical  hemorrhage,  for 
what  little  benefit  is  to  be  derived  from  their  employ- 
ment is  of  no  consequence  in  comparison  to  the  effici- 
ency of  other  methods  and,  moreover,  they  are  detri- 
mental to  subsequent  wound  healing.  In  superficial 
bleeding,  however,  topical  applications  of  adrenalin 
chloride  or  beech-wood  creosote  control  the  hemor- 
rhage very  satisfactorily. 

Shaving  of  the  surrounding  skin  is  not  always 
requisite,  but  thorough  cleansing  with  green  soap  is 
without  exception  of  great  importance.  This  should 
be  done  with  a  nail  brush,  if  the  condition  of  the  skin 
will  admit ;  but  if  bniised,  a  sterile  gauze  sponge  is 
preferable  because  the  brush  may  irritate  the  already 
tender  skin  and  be  a  source  of  additional  trauma.  It 
is  ridiculous  to  put  clean  gauze  on  dirty  skin,  and  the 
area  shaved  and  cleansed  should  always  extend 
beyond  the  limit  of  the  dressing. 

Irrigation  of   a  wound  with  hydrogen   peroxide 


2  8  MINOR  AND  EMERGENCY  SURGERY 

serves  to  loosen  bacteria,  coagulated  blood,  dirt  and 
foreign  bodies.  Although  peroxide  is  an  efficient 
deodorizer  and  cleansing  agent,  its  germicidal 
powder  is  feeble.  It  may  therefore  be  omitted 
when    dealing   with    an    apparently    clean    wound. 

The  variety  of  foreign  bodies  found  in  woimds  is 
almost  imlimited  and  we  should  be  on  the  lookout 
for  an3rthing  from  a  bacterium  to  a  limb  of  a  tree. 
It  is  important  that  a  wound  be  first  freed  of  all 
accumulated  blood  clots.  As  a  rule,  the  greater 
part  of  the  extraneous  material  may  be  removed 
by  irrigation  and  the  fingers,  but  if  these  prove 
unsuccessful  recourse  may  be  had  to  the  knife, 
forceps  or  curette.  Care  should  be  exercised  that 
the  efforts  to  dislodge  the  foreign  bodies  do  not  push 
them  in  further.  The  wound  may  be  sufficiently 
enlarged  to  facilitate  removal.  When  in.strum.enta- 
tion  is  necessary,  the  forceps  or  curette  should  be 
inserted  under  the  foreign  body,  so  that  it  may 
be  lifted  rather  than  pulled  out.  Bits  of  iron  or 
steel  are  often  easily  extracted  by  means  of  a  power- 
ful magnet. 

If  muscles,  nerves  or  strong  bands  of  fascia  have 
been  divided  they  should  be  sutured.  The  two  ends 
of  the  same  structure  must  be  positively  identified 
and  accurately  approximated.  The  suture  material 
selected  for  this  purpose  will  depend  upon  individual 
preference,  but  for  subcutaneous  work  it  should 
always  be  absorbable.  Plain  catgut,  chromic  catgut, 
kangaroo  tendon  and  iodine  catgut^  are  most  often 

^  Preparation  of  iodine  catgut — the  raw  strands  of  appropriate  sizes 
are  immersed  in  a  watery  solution  of  i  per  cent,  iodine  crystals  and  i  per 


ACCIDENTAL  WOUNDS  29 

used,  and  of  these  iodine  catgut  is  the  most  satisfac- 
tory. It  is  antiseptic  arid  aseptic,  impossible  to  in- 
fect (proved  by  bacteriological  experiments)  and  its 
tensile  strength  and  pliability  are  all  that  may  be 
desired.  It  is  easily  prepared,  thoroughly  reliable 
and  trivial  in  cost.  It  may  be  used  to  equal  ad- 
vantage in  all  manners  in  which  a  suture  or  ligature 
is  ever  applied. 

Occasionally  the  edges  of  a  wound,  especially  those 
of  the  lacerated  class,  may  be  very  irregular.  They 
should  be  trimmed  with  scissors,  all  tags  being  re- 
moved to  obviate  subsequent  sloughing  and  to  secure 
good  coaptation,  thus  minimizing  scar  tissue  forma- 
tion. 

Woimds  where  the  chances  of  obtaining  primary 
union  seem  to  be  good  are  best  closed  with  a  sub- 
cuticular suture  of  iodine  catgut.  It  should  be  intro- 
duced in  the  same  way  as  one  of  any  other  material ; 
but  the  upper  end  is  tied,  the  skin  pushed  up  on  the 
suture  and  the  lower  end  tied,  thus  markedly  de- 
creasing the  length  of  the  wound  (Fig.  i).  The  sub- 
ctiticular  suture  obviates  the  necessity  of  suture  re- 
moval later  on.  If  the  nature  of  the  wound  is  such 
that  it  seems  doubtful  or  improbable  that  union  by 
first  intention  can  be  brought  about,  it  should  be 
entirely  or  partially  closed  with  interrupted  sutures, 
avoiding  undue  tension.  Accurate  approximation  of 
the  skin  margins  is  essential,  but  constriction  causes 
sloughing.  The  knots  should  always  be  tied  well  to 
one  side  and  not  directly  over  the  line  of  union  (Fig. 

cent,  potassium  iodide  crystals,  allowed  to  remain  for  eight  days  and 
then  transferred  to  a  dry  sterile  jar  covered  with  sterile  gauze. 


3°   - 


MINOR  AND  EMERGENCY  SURGERY 


2).;  otherwise  they  may  become  entangled  in  the 
healing  process  and  tend  to  re-open  the  wound  when 
removed.    The  contra-indications  for  the  use  of  iodine 


Fig. 


Subcuticular  suture  introduced  and  tied. 


catgut  are  the  probability  of  prolonged  sloughing  and 
great  strain  on  the  sutures,  because  the  gradual  ab- 


FiG.  2. — a,  Correct  and  b  incorrect  method  of  tying  sutures. 

sorption  of  the  sutures  weakens  their  support.  It  is 
then  prudent  to  re-inforce  or  replace  them  with 
through-and-through  silk  or  silkworm-gut  sutures, 


ACCIDENTAL   WOUNDS  31 

Wounds  of  the  lips,  tongue  and  eyelids  are  best  closed 
with  fine  black  silk,  because  of  the  cosmetic  effect. 

Extensive  wounds  or  those  accompanied  by  severe 
contusion  in  which  more  or  less  sloughing  seems  likely 
to  ensue  should  be  drained.  The  most  satisfactory 
material  for  this  purpose  is  rubber  tubing,  except  in 
small  wounds  which  may  be  drained  by  introducing 
a  little  roll  of  gutta-percha  tissue.  Naturally,  drain- 
age should  always  be  encouraged  toward  the  most 
dependent  portion  of  the  injured  area.  Position, 
then,  is  an  important  factor.  Plain  sterile  or 
medicated  gauze,  particularly  that  impregnated  with 
iodoform,  has  been  widely  employed  for  drainage, 
but  careful  observation  will  demonstrate  that  gauze 
performs  the  function  of  a  cork  rather  than  of  a  drain. 
It  will  rapidly  absorb  serum  or  pus  until  it  is  satu- 
rated but  will  not  promote  drainage  beyond  that 
point.  For  packing  clean  cavities,  however,  plain 
gauze  strips  will  be  found  exceedingly  useful. 

The  best  method  of  sterilizing  a  dirty  woimd  is 
to  inject  tincture  of  iodine  directly  into  it  with  an 
ordinary  medicine  dropper,  previous  to  tying  the 
sutures  in  the  skin.  Iodine  is  an  agent  of  high 
germicidal  potency,  endowed  with  remarkable  pene- 
trating power  and  one  of  the  most  satisfactory 
and  reliable  antiseptics  at  our  command.  Even 
when  sloughing  is  imminent,  the  iodine  will  hasten 
separation  of  the  slough,  limit  the  formation  of  pus, 
and  stimulate  granulation. 

The  primary  dressing  of  all  wounds  should  con- 
sist of  several  layers  of  sterile  gauze  saturated  with 
a  liquid :  water,  solution  of  aluminum  acetate,  equal 


32  MINOR  AND  EMERGENCY  SURGERY 

parts  of  alcohol  and  witch  hazel,  etc.  They  are 
best  used  lukewarm,  as  the  continuous  application 
of  extreme  cold  depresses  the  vitality  of  the  parts. 
Bichloride  of  mercury  solutions  have  been  more 
or  less  universally  employed  for  this  purpose,  but 
they  are  inferior  to  others  because  they  may  excite 
a  dermatitis  and  may  injure  the  surgeon's  hands 
after  prolonged  use.  Contrary  to  the  belief  of 
many,  the  bichloride  does  not  entirely  destroy 
the  bacteria  but  only  coagulates  the  albumen  of 
the  capsule.  Far  better  results  will  be  obtained 
from  the  use  of  the  above-mentioned  agents,  es- 
pecially if  used  in  conjimction  with  iodine.  The 
popular  "carbolic  wash"  should  never  be  used  for 
a  wet  dressing,  as  the  solution  itself  is  extremely 
poisonous  and  carbolic  gangrene  often  follows. 
A  wet  dressing  should  always  be  bandaged  with 
gauze  so  that  the  whole  may  be  moistened  from 
time  to  time.  Glycerine  is  a  valuable  aid  in  keep- 
ing the  dressings  wet,  since  its  powerful  hygro- 
scopic powers  promote  drainage  and  hasten  slough- 
ing. The  practice  of  covering  gauze  compresses 
with  gutta-percha  tissue  and  bandaging  with  muslin 
is  unsatisfactory,  because  the  moisture  will  evapo- 
rate in  spite  of  these  precautions  and  then  the 
dressing  cannot  be  soaked  again  without  removal. 

Although  a  great  deal  may  be  learned  from  the 
text-book  illustrations,  bandaging  is  an  art  that 
can  be  mastered  by  constant  practice  only.  Ob- 
servation of  the  following  general  principles  will 
prove  useful: 

Always  "fix"  the  bandage  at  the  start. 


ACCIDENTAL   WOUNDS  ^^ 

Avoid  wrinkles  and  creases  as  much  as  possible. 

Be  careful  that  the  bandage  fits  smoothly  and 
snugly,  yet  does  not  constrict. 

Always  bandage  from  below  upward;  toward 
the  trunk. 

Remember  that  a  bandage  that  does  not  commence 
at  the  fingers  or  toes  tends  to  produce  edema  of 
the  uncovered  part. 

Never  bury  the  end  of  a  bandage  applied  to  the 
head,  but  leave  it  free  so  that  it  may  be  tied  to 
the  other  end. 

A  bandage  that  requires  pins  or  adhesive  plaster 
to  maintain  its  position  has  not  been  properly 
applied. 

Split  or  cut  the  free  end  of  a  bandage  longitudi- 
nally, tie  a  knot  in  it  and  this  leaves  two  ends  to 
tie  together. 

Rest  of  the  injured  area,  for  self-evident  reasons, 
is  of  great  importance,  since  motion  and  friction 
disturb  the  continuous  apposition  of  the  wound 
surfaces.  Cases  of  severe  wounds  should  be  con- 
fined to  bed,  particularly  if  accompanied  by  shock. 
Usually  the  limited  motion  of  the  part  occasioned 
by  the  dressing  is  sufficient,  although  frequently 
a  splint  will  prove  a  valuable  adjunct.  When  a 
joint  has  been  injured,  the  limb  should  be  im- 
mobilized in  the  position  that  will  be  most  useful 
to  the  patient  in  event  of  permanent  stiffness. 

Emergency  treatment  of  wounds  should  consist  of 
those  measures  only  that  are  absolutely  essential 
for  the  maintenance  of  favorable  conditions,  and 
the   permanent  dressing  should  be   deferred  until 

3 


34     MINOR  AND  EMERGENCY  SURGERY 

the  procedures  can  be  continued  under  rigid  aseptic 
circumstances.  The  arrest  of  hemorrhage,  preven- 
tion of  swelling,  removal  of  foreign  material  (pro- 
vided it  can  be  done  quickly),  exclusion  of  ad- 
ditional foreign  material  and  control  of  shock  are 
all  that  require  immediate  attention.  The  first 
may  be  obtained  by  a  clamp,  tourniquet  or  the 
pressure  of  the  dressing;  the  second  and  fourth  by 
the  moist  gauze  and  the  fifth  by  the  usual  remedial 
agents  for  shock.  Wounds  of  the  abdomen  from 
which  a  loop  of  the  intestine  or  the  omentum  pro- 
trudes should  be  covered  with  gauze  wrung  out 
in  hot  saline  solution,  and  no  effort  to  replace  it 
immediately  should  be  made. 

Passive  hyperemia,  after  the  method  devised 
by  Bier,  will  often  prove  a  useful  adjunct  in  the 
treatment  of  wounds,  especially  in  those  that  have 
become  infected.  It  is  best  induced  by  several 
superimposed  layers  of  an  Esmarch  or  Martin  rub- 
ber bandage.  The  constrictor  should  always  be 
applied  proximally  over  the  healthy  tissue,  should 
never  give  rise  to  paresthesia  or  pain,  and  the 
pulse  should  be  perceptible  below  the  constriction. 
Dressings  must  be  temporarily  removed  from  the 
wound  and  be  replaced  by  loose  sterile  gauze,  to 
permit  hyperemia.  For  further  details  and  technic 
the  reader  is  referred  to  works  on  the  subject. 

After-treatment  of  Wounds. — Equal  care  in  all 
aseptic  and  antiseptic  precautions  should  be  exer- 
cised throughout  the  after-treatment  as  when  apply- 
ing the  primary  dressing.  The  surgeon's  hands, 
instruments    and    dressings    should    be    sterile.     A 


ACCIDENTAL  WOUNDS  35 

simple  and  efficient  technic  of  hand  sterilization 
consists  of  energetic  scrubbing  with  green  soap, 
followed  by  immersion  in  a  watery  solution  of 
iodine ;  a  dram  of  the  tincture  to  a  pint  of  hot  water. 
The  staining  of  the  skin  is  inconsiderable  and  even 
its  prolonged  use  does  not  injure  the  hands  in  the 
slightest.  Iodine  must  not  be  used  for  the  repeated 
sterilization  of  steel  instruments,  because  of  its  tar- 
nishing action.  They  are  satisfactorily  sterilized  by 
boiling  in  a  I  per  cent,  solution  of  carbonate  of  soda. 
The  gauze  compresses,  bandages,  etc.,  should,  of 
course,  be  previously  sterilized  by  compressed  steam. 
All  dressings  should  be  kept  wet  for  at  least  three 
days.  If  there  are  then  no  evidences  of  sloughing  or 
pus  formation,  dry  sterile  gauze  is  all  that  will  be 
required.  A  neat  dressing  for  small  clean  wounds 
consists  of  little  sterile  cotton  painted  and  fastened 
down  with  collodion,  but,  as  it  does  not  provide  for 
the  absorption  of  wound  secretion,  it  should  be 
used  only  in  clean  cases  in  which  hemostasis  has 
been  exact.  The  appearance  of  heat,  redness  and 
swelling  denotes  pus  formation  and  is  indication  for 
the  immediate  removal  of  one  or  more  sutures  and 
the  institution  of  drainage.  The  body  temperature 
is  also  a  reliable  index  of  the  condition  of  the  wound. 
Tincture  of  iodine  should  be  dropped  along  the  line 
of  union,  and  under  it  if  the  wound  is  being  drained, 
at  each  dressing.  If  the  granulating  process  is  slug- 
gish, sprinkling  the  surface  with  powdered  naphtha- 
lin  crystals  and  applications  of  balsam  of  Peru  will 
hasten  it.  When  healing  is  markedly  retarded  with- 
out some  apparent  cause,  it  is  often  due  to  diabetes. 


36  MINOR  AND  EMERGENCY  SURGERY 

The  many  dusting  powders  on  the  market  are  of 
little  practical  value;  they  are  expensive,  but 
feebly  antiseptic  and  make  a  paste  with  the  serum 
that  exudes  from  the  wound,  thus  causing  the  gauze 
to  adhere  to  the  line  of  union.  Rarely,  if  ever,  will 
a  dusting  powder  destroy  pyogenic  organisms  and 
prevent  pus  formation.  Iodoform  has  been  exten- 
sively employed  as  a  dusting  powder  and  incorpo- 
rated in  gauze,  although  it  possesses  but  few  of  the 
virtues  of  the  tincture  of  iodine.  It  liberates  but  a 
miinute  quantity  of  iodine,  its  odor  is  disagreeable 
and  iodism  frequently  follows  its  use. 

Contused  wounds  are  the  most  common  of  all 
wounds  encountered  in  surgical  practice.  They  are 
accompanied  by  more  or  less  pain,  swelling  and  dis- 
coloration of  the  skin.  Although  they  may  appear 
insignificant  at  first,  sloughing  of  the  soft  parts  may 
subsequently  occur,  even  though  the  skin  is  not 
visibly  broken.  This  may  be  due  to  hematogenous 
infection  or  occur  externally  through  a  minute  fissure 
in  the  skin.  It  should  not  be  forgotten  that  slough- 
ing may  extend  into  a  large  blood-vessel  and  give 
rise  to  secondary  hemorrhage.  A  hematoma  usu- 
ally forms,  which  eventually  terminates  in  either 
absorption  or  purulent  resolution.  Diligent  search 
should  always  be  made  for  fracture  of  underlying 
bones.  The  appearance  of  a  contused  wound  of  the 
scalp  is  often  misleading,  because  of  the  circum- 
scribed swelling  with  a  central  depression,  known  as 
' '  Pott '  s  puffy  tumor . ' '  Should  accompanying  symp- 
toms of  cerebral  concussion  exist,  the  condition  may 
closely  resemble  fracture  of  the  skull,  and  manifestly 


ACCIDENTAL  WOUNDS  ^^ 

the  reverse  is  true.  Contused  wounds  of  the  abdo- 
men should  be  kept  under  close  observation  for  at 
least  a  week,  for  if  severe  they  nearly  always  show 
shock  early  and  internal  hemorrhage  or  rupture  of  a 
viscus  may  occur  at  any  time.  The  apparent  absence 
of  damage  to  the  skin  does  not  necessarily  exclude 
internal  injury.  Rupture  of  a  solid  viscus  or  of  the 
omentum  generally  results  in  internal  hemorrhage; 
perforation  of  a  hollow  viscus  is  invariably  followed 
by  peritonitis.  Likewise,  a  blow  may  produce  sub- 
mucous hemorrhage  and  subsequently  ulcer  of  the 
stomach  or  intestine.  Increasing  rapidity  of  the 
pulse  is  characteristic  of  rupture  and  no  patient 
should  be  considered  out  of  danger  if  the  pulse  is 
rapid.  When  injury  to  the  bladder  or  urethra  is 
suspected,  the  gentle  passing  of  a  soft-rubber  catheter 
will  help  to  clear  up  the  diagnosis.  A  contusion  may 
cause  a  bursitis,  arthritis,  periostitis  or  osteomyelitis. 
A  tubercular  process  is  particularly  likely  to  be 
excited  by  a  contusion,  especially  in  a  joint. 

Contused  wounds  should  be  dressed  immediately 
with  gauze  saturated  with  water,  aluminum  acetate 
solution  or  lead  and  opium  wash.  This  will  tend  to 
prevent  swelling,  limit  subcutaneous  oozing,  allay 
pain,  favor  drainage  and  promote  absorption  of  the 
effusion.  An  ice  bag  should  be  applied  to  severe 
contusions  about  the  head,  especially  if  accompanied 
by  concussion.  When  sound  teeth  are  knocked  out, 
they  should  be  replaced  in  their  sockets,  as  re-attach- 
ment is  often  possible.  Proper  position  may  be 
maintained  by  fastening  them  to  adjacent  teeth 
with  silver  wire  or  silk.     The  accumulation  of  blood 


38      ,      MINOR  AND  EMERGENCY  SURGERY 

under  the  nail  following  a  contusion  is  often  ex- 
tremely painful ;  the  cuticle  overlapping  the  base  of 
the  nail  should  be  gently  lifted  with  a  sharp  knife  and 
the  blood  squeezed  out.  A  bursitis  or  synovitis  with 
effusion  of  serum  or  synovial  fluid  should  be  aspirated 
under  rigid  aseptic  precautions. 

The  slightest  sign  of  pus  under  the  skin  after  a  con- 
tusion warrants  incision  at  once.  If  the  sloughing  is 
at  all  extensive,  counter-openings  should  be  made  by 
introducing  a  long  dressing  forceps  closed  and  incising 
the  skin  which  is  made  prominent  by  the  tip.  One  or 
more  fenestrated  rubber  drainage  tubes  of  convenient 
size  may  then  be  inserted  by  opening  the  jaws  of  the 
forceps,  grasping  one  end  of  the  tube  and  withdraw- 
ing the  forceps.  Proper  position  may  be  maintained 
by  fastening  each  end  with  a  sterile. safety  pin.  The 
incisions  should  always  be  made  parallel  to  the  course 
of  the  blood-vessels,  and  never  at  right  angles  (Fig. 
3).  The  extent  of  drainage  will  depend  upon  the 
amount  of  sloughing,  and  the  length  of  the  tubes  may 
be  diminished  as  desired.  The  necrotic  tissue  should 
be  excised  at  each  dressing  and  the  wound  irrigated 
through  the  drainage  tubes  by  means  of  a  fountain 
syringe  or  a  Valentine  irrigator  with  peroxide,  fol- 
lowed by  an  iodine  solution :  a  dram  of  the  tincture 
to  a  pint  of  water.  A  Davidson  syringe  should  not 
be  used  because  the  pressure  exerted  cannot  be 
accurately  gauged.  The  appearance  of  bleeding  de- 
notes the  cessation  of  necrosis  and  the  beginning  of 
granulation.  These  wounds  necessarily  close  from 
below  upward,  so  care  should  be  taken  that  the 
skin  margins  do  not  close  primarily  and  thus  obstruct 


ACCIDENTAL   WOUNDS 


39 


drainage.  Dead  skin  should  be  scraped  off  with 
a  dull  knife  or  gauze  saturated  with  alcohol.  De- 
struction of  the  arterial  supply  with  necrosis  of  bone 
indicates  amputation.  The  surgeon  should  be  con- 
stantly on  the  alert  for  intra-abdominal  complications 
following  contused  wounds  of  the  abdomen.     Con- 


FlG.  3. — a.  Incisions  for  drainage  tubes  made  correctly;   b,  incisions  for 
drainage  tubes  made  incorrectly. 


cealed  hemorrhage  or  perforation  of  a  viscus  ne- 
cessitates immediate  abdominal  section,  unless  the 
patient  is  moribund. 

Lacerated  wounds  are  due  to  semi-sharp  trau- 
matism or  to  a  tearing  force.  Avulsion  of  a  portion 
of  a  limb  or  complete  tearing  off  of  the  scalp  may  oc- 


40 


MINOR  AND  EMERGENCY  SURGERY 


cur  as  the  result  of  machinery  and  railroad  accidents, 
but  fortimately  such  extensive  lacerations  are  ex- 
ceptional. The  usual  picture  presenting  is  a  long 
jagged  wound,  bleeding  freely  and  contaminated  by 
hair,  dirt  and  other  foreign  material.  They  should 
be  especially  examined  for  severed  tendons.  A 
fissure  fracture  of  the  skull  should  be  searched  for  in 


Fig.  4. — Silkworm-gut  strands  introduced  for  drainage. 

all  lacerated  wounds  of  the  scalp.  Always  remember 
that  a  normal  skull  suture  can  be  wiped  clean, 
whereas  the  red  line  of  a  fracture  cannot  be  elimi- 
nated. 

Simple  lacerated  wounds  should  be  treated  on 
general  principles.  Turpentine  and  benzine  are  ex- 
cellent agents  for  dissolving  the  grease  that  is  often 
found  smearing  the  tissues.     Surprisingly  good  re- 


ACCIDENTAL   WOUNDS  41 

suits  are  frequently  obtained  in  cases  of  avulsion  of 
the  scalp,  due  largely  to  its  vascularity.  These  are 
ideal  cases  for  the  transplantation  of  skin  flaps. 
Thorough  removal  of  all  hair  from  a  scalp  wound  and 
the  surrounding  skin  is  of  great  importance.  A 
simple  and  efficient  method  of  draining  an  extensive 
scalp  wound  consists  of  inserting  a  number  of  strands 
of  silkworm  gut  lengthwise  before  tying  the  sutures. 
(Fig.  4).  Continuous  warm  irrigation  is  especially 
applicable  to  severe  lacerated  wounds  of  the  ex- 
tremities. Avulsion  of  a  limb  is  almost  synonymous 
with  a  traiunatic  amputation  and  will  not  be  con- 
sidered here. 

Lacerated  wounds  properly  dressed  at  first  will  re- 
quire but  little  after-treatment.  Skin  sutures  should 
be  removed  on  the  eighth  day,  if  of  non-absorbable 
material.  They  should  be  gently  lifted  on  one  side 
and  snipped  with  scissors  close  to  the  skin,  to  avoid 
dragging  anything  through  the  stitch  hole  that  has 
been  outside  the  skin  (Fig.  5). 

Incised  wounds  are  due  to  sharp-edged  bodies  en- 
tering the  tissues.  They  are  frequently  deeper  than 
their  superficial  appearance  indicates,  since  they  gap 
very  little ;  the  integrity  of  the  underlying  structures 
should,  therefore,  be  carefully  investigated.  Incised 
scalp  wounds  bleed  freely  because  the  density  of  the 
scalp  retards  retraction  of  the  blood-vessels.  A 
frequently  occurring  type  of  incised  wound  is  cut- 
throat. In  these  cases  the  position  of  the  carotid 
arteries  is  such  that  they  escape  injury  as  a  rule  and 
the  greatest  danger  is  not  hemorrhage  but  sepsis. 
Attempt  at  suicide  is  generally  made  between  the 


42 


MINOR  AND  EMERGENCY  SURGERY 


hyoid  bone  and  the  thyroid  cartilage,   and  pneu- 
monia is  a  common  sequel. 

Incised  woimds  usually  heal  by  primary  union  and 
it  is  safe  to  permit  this,  provided  that  iodine  is  used. 
It  will  not  be  amiss  to  repeat  that  severed  important 
structures  should  be  accurately  approximated,  as  it 
is  a  source  of  great  mortification  for  the  surgeon  to 
find  that  certain  muscles  are  useless  after  a  wound 


Fig.  5. — a,  Correct  and  h  incorrect  method  of  removing  sutures. 

has  entirely  closed.  A  cut-throat  should  never  be 
sutured  tightly;  first,  because  of  the  danger  of  sepsis, 
and  secondly,  because  the  retained  extravasation 
may  press  upon,  or  enter  if  injured,  the  trachea,  thus 
asphyxiating  the  patient.  The  head  should  be 
strongly  flexed  so  that  position  may  favor  recovery. 
The  dressings  should  be  kept  hot  and  moist  to  prevent 
the  entrance  of  cold  air  and  septic  matter,  thus  guard- 


ACCIDENTAL  WOUNDS 


43 


ing  against  pneiimonia.  Food  and  stimulation  may- 
be administered  by  rectal  enemata. 

Punctured  wounds  are  due  to  pointed  objects 
entering  the  tissues  to  a  variable  depth,  are  apt  to 
injure  important  structures  and,  if  penetrating  a 
cavity,  infection  and  suppuration  are  likely  to  result. 
Part  of  the  object  inflicting  the  injury  may  break 
off,  leaving  a  foreign  body  in  the  woimd.  A  person 
falling  from  a  height  may  strike  upon  some  pointed 
object,  impaling  a  portion  of  the  body.  Penetrat- 
ing wounds  are  to  be  distinguished  from  perforating 
wounds;  the  former  enter  a  cavity,  while  the  latter 
enter  as  well  some  organ  or  viscus  within  the  cavity. 
It  is  obvious  that  punctured  wormds  should  be  care- 
fully scrutinized  for  the  integrity  of  the  subjacent 
important  structures  and  for  foreign  bodies.  Pleurisy 
and  pneumonia  not  infrequently  follow  punctured 
wounds  of  the  chest,  hence  the  necessity  for  keeping 
these  cases  under  close  observation.  Penetrating 
wounds  of  the  abdomen  may  gap  sufficiently  to  allow 
protrusion  of  the  omentum,  intestines  or  other  vis- 
cera, and  are  sometimes  sufficiently  extensive  to 
permit  an  almost  complete  evisceration.  Naturally, 
there  is  profound  shock  therewith,  and  great  danger 
of  hemorrhage,  infection  and  injury  to  the  viscera. 

All  ptmctured  wounds  should  be  drained.  If  a  for- 
eign body  remains  in  the  woimd,  it  will  usually  be 
necessary  to  enlarge  it  to  permit  extraction.  A 
wound  communicating  with  a  joint  must  never  be 
entirely  closed,  owing  to  the  rapidity  with  which 
synovial  membrane  absorbs  toxic  material.  The 
danger  of  sepsis  is  too  great  to  justify  an  effort  to 


44  .         MINOR  AND  EMERGENCY  SURGERY 

secure  primary  union.  Every  punctured  wound  of 
the  peritoneal  cavity  demands  immediate  exploratory 
laparotomy.  Don't  wait  for  symptoms  of  perfora- 
tion or  internal  hemorrhage  before  opening  the 
abdomen. 

Poisoned  wounds  are  due  to  infection  through  an 
abrasion  of  the  skin  or  through  the  sweat  or  sebaceous 
glands  and  are  particularly  likely  to  result  from  con- 
ducting dissections  and  post-mortem  examinations. 
The  usual  picture  presenting  is  that  of  cellulitis,  and 
later  septicemia.  The  stings  of  insects  and  the 
bites  of  snakes  and  animals  may  introduce  a  special 
poison  into  the  economy,  and  here  the  symptoms  are 
those  of  the  poison  plus  cellulitis.  Poisoned  wounds 
due  to  micro-organisms  are  commonly  termed  in- 
fected wounds.  The  treatment  may  be  summed  up 
in  five  words:  incision,  evacuation,  iodine,  drainage 
and  wet  dressing.  The  treatment  of  infected  wounds 
with  vaccines,  based  on  the  opsonic  theory  of  Wright, 
has  yielded  but  poor  results  in  the  author's  experience. 
Somewhat  better  results,  however,  have  been  ob- 
tained from  the  use  of  autogenous  vaccines  than 
from  stock  preparations.  Poisoned  wounds  due  to 
other  toxic  substances  also  require  prompt  incision 
and  drainage.  The  wound  should  be  shut  off  from 
the  general  circulation  by  means  of  a  ligature  and 
bleeding  is  to  be  encouraged,  to  prevent  the  absorption 
of  toxic  material.  Snake  bites  are  best  treated  by 
excision  of  the  wotmd  and  potassium  premanganate 
dressings.  Patients  bitten  by  a  rabid  animal  should 
be  referred  to  a  Pasteur  institute,  after  cauterizing 
the  wound  with  carbolic  acid  and  alcohol  or  the  acttial 


ACCIDENTAL  WOUNDS  45 

cautery.     A  nutritious  diet  and  tonics  in  full  doses 
should  be  given  in  all  cases  of  poisoned  wounds. 

Gunshot  wounds  are  due  to  the  explosion  of  gun- 
powder, nitroglycerine,  dynamite  and  other  power- 
ful explosives.  The  wound  itself  may  be  produced 
by  powder,  wadding,  lead  or  steel  bullets,  or  other 
missiles.  Blank  cartridge  wounds  are  particularly 
dangerous  because  of  the  frequent  development  of 
tetanus.  If  a  fire-arm  is  discharged  at  short  range, 
particles  of  unburned  powder  may  be  driven  into  the 
skin.  These,  however,  are  of  little  consequence  in 
themselves,  unless  on  the  face  where  the  cosmetic 
effect  is  of  considerable  importance.  Needless  to 
say,  even  a  single  grain  of  powder  may  severely 
injure  the  eye.  A  gunshot  wound  may  have  but  a 
single  aperture,  the  edges  of  which  are  inverted,  or,  if 
the  missle  emerges,  a  wound  of  exit  also,  the  edges  of 
which  are  everted.  The  presence  of  one  or  more 
wounds  will,  as  a  rule,  indicate  whether  or  not  the  for- 
eign body  remains  in  the  tissues.  A  bullet  is  likely 
to  be  deflected  from  its  apparent  course  by  striking 
firm  tissues,  cartilage  or  bone.  In  simple  bullet 
wounds,  the  heat  generated  by  the  passage  of  the 
projectile  is  sufficient  to  sterilize  the  tract  so  that 
infection  is  not  common  except  in  the  peritoneal 
cavity.  The  amount  of  contusion  of  the  soft  parts 
will  vary  inversely  with  the  velocity  of  the  bullet; 
the  slower  the  bullet  travels  the  greater  will  be  the 
contusion  and  laceration.  The  resistance  of  the 
parts  decreases  the  speed  of  the  projectile  consider- 
ably, so  that  there  is  generally  more  destruction  of 
tissue  at  the  wound  of  exit  than  at  the  point  of 


46^  MINOR  AND  EMERGENCY  SURGERY 

entrance.  If  the  bullet  is  still  within  the  body,  its 
exact  location  should  be  determined  as  accurately 
as  possible  without  inflicting  further  damage  upon 
the  injured  parts.  Inspection,  palpation  and  the 
:v;-ray  may  be  safely  employed  for  this  purpose,  but 
rough  probing  and  blind  dissection  are  harmful 
and  imjustifiable.  When  a  large  blood-vessel  that 
cannot  be  reached  easily  has  been  injured,  enlarge- 
ment of  the  wound  to  control  hemorrhage  is  indi- 
cated. A  bullet  may  lie  deeply  imbedded  in  the 
tissues  for  years  without  giving  rise  to  any  annoying 
symptoms.  In  general,  gunshot  wounds  may  be  con- 
sidered as  differing  but  slightly  from  contused  and 
lacerated  wounds  and  compound  factures.  The 
severity  of  the  damage  sustained  by  the  tissues  may 
vary  from  an  insignificant  sterile  wound,  requiring 
little  or  no  attention,  to  the  destruction  of  a  large 
area,  necessitating  amputation  of  an  entire  limb. 
In  severe  gunshot  wounds,  as  in  other  extensive 
injuries,  there  is  profound  shock. 

Powder  grains  beneath  the  skin  should  be  picked 
out  with  a  needle  or  sharp  bistoury  or  scrubbed  out 
with  a  stiff  brush  -under  anesthesia  as  soon  as  pos- 
sible, because  the  longer  they  are  allowed  to  remain 
the  more  pronounced  will  be  the  resulting  indelible 
blue  stain.  All  cases  of  gunshot  wotmds  contami- 
nated with  soil  and  all  blank  cartridge  wounds 
should  receive  an  immunizing  dose  of  tetanus  anti- 
toxine.  An  effort  to  save  all  tissue  not  entirely 
destroyed  should  be  made,  and  the  recuperating 
power  of  a  part  will  vary  in  direct  proportion  to  its 
blood   supply.     A  bullet  deeply  imbedded  in   the 


ACCIDENTAL  WOUNDS  47 

tissues  should  be  accurately  located  with  the  x-ray. 
Its  subsequent  removal  will  then  depend  upon  the 
situation  of  the  bullet,  the  amount  of  damage  it 
has  inflicted  and  the  patient's  condition.  In  every 
bullet  wound  of  the  abdomen  immediate  exploratory 
laparotomy  is  imperative,  unless  it  is  positive  that 
the  peritoneal  cavity  has  not  been  entered,  for  the 
mesentery,  intestine,  stomach,  bladder  or  some  other 
important  structure  is  almost  invariably  injured. 
The  entire  cavity  and  its  contents  should  be  explored 
to  assure  that  no  perforations  are  overlooked. 


CHAPTER  III. 
TRAUMATIC  INJURIES  OF  JOINTS. 

Those  inflammations  resulting  from  joint  injuries 
depend  upon  the  nature  and  severity  of  the  inflicting 
violence  and  the  location  sustaining  the  damage. 
As  a  inile,  low  grade  inflammations,  such  as  osteo- 
arthritis and  arthritis  deformans,  result  from  disease 
rather  than  traumatism,  and  a  constitutional  di- 
athesis should  therefore  always  be  accorded  due 
consideration.  So-called  "hysterical  joints"  are 
often  the  source  of  serious  error  and  should  be 
excluded.  In  such  instances,  the  patient  is  of  a 
hysterical  or  neurotic  temperament,  the  skin  is  more 
sensitive  to  pressure  than  the  underlying  parts,  char- 
acteristic attitude  is  lacking  and  although  the  patient 
will  state  that  the  joint  cannot  be  moved,  he  will 
move  it  unconsciously.  Mensuration  and  compari- 
son with  the  joint  on  the  opposite  side  are  valuable 
aids  in  the  examination  of  joints.  In  all  joint  in- 
flammations muscular  rigidity  causes  an  apparent 
loss  of  motion  far  beyond  what  is  absolutely  present. 
This  condition  must  be  differentiated  from  ankylosis, 
but  since  anesthesia  will  dissipate  muscular  rigidity, 
the  diagnosis  is  easy.  True  joint  crepitus  depends 
almost  entirely  for  its  existence  upon  roughness  of 
the  articular  cartilages.  Crepitus  is  always  absent 
in  complete  disorganization. 

48 


TRAUMATIC  INJURIES  OF  JOINTS  49 

BURSITIS. 

Bursas  are  distinct  sacs  but  sometimes  communi- 
cate with  joints.  The  types  of  bursitis  from  a 
clinical  view-point  are:  (i)  serous,  (2)  suppurative, 
(3)  chronic,  (4)  tubercular  and  (5)  syphilitic. 
Although  any  of  the  normal  or  anomalous  bursas 
m.ay  be  subjected  to  direct  violence,  bursitis  is 
most  frequently  observed  in  front  of  the  patella 
(housemaid's  knee),  behind  the  olecranon  process, 
and  over  the  great  toe  (bunion) , 

Simple  serous  bursitis  is  best  treated  with  rest 
of  the  part,  coimter-irritation  and  the  ice  bag.  The 
bursa  may  be  aspirated  and  pressure  exerted  by 
the  application  of  an  elastic  bandage.  If  these 
m.easures  fail  to  cure,  complete  excision  of  the 
bursa  is  indicated. 

Prepatellar  bursitis  is  frequently  suppurative, 
and  unless  speedily  drained  the  pus  quickly  invades 
the  cellular  tissues.  If  the  infection  is  still  lirnited 
to  the  bursa  itself,  incision,  drainage  and  packing 
the  cavity  with  gauze  may  effect  a  cure,  as  ad- 
hesions rapidly  obliterate  the  sac.  Not  infrequently, 
however,  it  will  be  necessary  to  dissect  out  the 
bursa  and  drain. 

Chronic  serous  bursitis  can  often  be  cured  by 
tapping  and  afterwards  injecting  equal  parts  of 
carbolic  acid  and  tincture  of  iodine.  Tubercular 
and  syphilitic  bursae  require  excision.  Great  care 
should  be  exercised  that  the  adjacent  joint  is  not 
opened. 

In  the  treatment  of  bimion,  it  will  often  be  a 
4 


50  MINOR  AND  EMERGENCY  SURGERY 

great  temptation  to  temporize  with  circular  felt 
or  plaster  shields,  or  to  incise  and  drain  the  joint. 
These  measures  do  not  entirely  relieve  the  con- 
dition, and  removal  of  the  thickened  outer  condyle 
of  the  metatarsal  bone  is  essential  to  complete  cure. 
An  incision  should  be  made  between  the  great  toe 
and  the  next  one,  and  the  phalanx  dislocated. 
The  head  of  the  metatarsal  bone  may  now  be  re- 
sected from  the  inside,  thus  obviating  a  lateral 
scar  to  rub  on  the  patient's  shoe. 

TRAUMATIC  SYNOVITIS. 

This  condition  usually  begins  as  an  acute  infec- 
tion, although  chronic  synovitis  frequently  occurs 
as  the  result  of  an  uncured  acute  inflammation. 
The  joint  fills  up  with  serum  a  few  hours  after  the 
injury,  there  being  but  slight  local  heat  and  pain 
(aggravated  by  pressure  or  forced  motion),  while 
redness  is  never  present.  The  swelling  is  always 
more  pronounced  where  the  protection  of  the 
muscles  and  other  tissues  is  least.  When  the 
synovitis  has  persisted  for  a  considerable  length  of 
time,  the  patient  will  experience  a  sense  of  weakness 
and  insecurity  in  the  joint,  accompanied  by  more 
or  less  limitation  of  motion  and  muscular  atrophy. 
The  prognosis  is  excellent,  except  in  debilitated 
subjects  in  whom  it  occasionally  terminates  in  sup- 
puration. 

The  treatment  is  simple.  A  snug  dressing  of 
lead  and  opium  wash,  covered  with  an  ice  bag, 
and  the  placing  of  the  joint  at  rest  temporarily  by 
means  of  an  elastic  bandage,   adhesive   straps   or 


TRAUMATIC  INJURIES  OF  JOINTS  51 

splints  are  usually  sufficient  to  effect  restoration 
of  function  and  a  complete  cure  in  a  few  days. 
In  the  more  severe  and  prolonged  cases  it  will  be 
necessary  to  aspirate  the  effusion  under  rigid  aseptic 
precautions  and  follow  with  fixation  of  the  joint 
and  counter-irritation.  Rarely,  incision  and  drain- 
age of  the  joint  are  required  to  relieve  a  suppura- 
tive process.  Passive  motion,  massage  and  hot  air 
baths  are  useful  adjuvants  in  the  after-treatment. 

TRAUMATIC  ARTHRITIS. 

Acute  arthritis  is  a  simultaneous  inflammatory 
involvement  of  all  the  structures  comprising  a 
joint,  and  with  few  exceptions  is  due  to  pyogenic 
organisms,  introduced  through  an  open  wound. 
It  may  begin  as  a  purulent  synovitis  or  may  involve 
the  entire  joint  primarily.  Likewise,  it  may  occur 
secondarily  to  an  acute  osteomyelitis.  The  syno- 
vial membrane  becomes  succulent,  the  quantity 
of  synovial  fluid  is  rapidly  increased,  the  cartilages 
necrose  and  erode  and  the  ligaments  soften.  Un- 
less drainage  is  immediately  instituted,  the  capsule 
may  perforate  and  the  pus  peiTQeate  the  bone  and 
soft  structures  above  and  below  the  joint.  The 
pain  and  tenderness  are  far  greater  than  in  synovitis 
and  all  the  manifestations  of  a  local  and  general 
septic  process  soon  present  themselves.  Grating 
on  motion  may  or  may  not  be  present,  depending 
upon  the  degree  of  fixation  of  the  joint  occasioned 
by  the  rigidity  of  the  adjacent  muscles. 

Since  a  peri-articular  pyemic  inflammation  may 
simulate  a  true  arthritis,  it  is  wise  to  aspirate  the 


"52  MINOR  AND  EMERGENCY  SURGERY 

joint  for  diagnostic  confirmation.  Until  the  diagno- 
sis is  definitely  established,  a  splint  and  ice  bag 
may  be  employed. 

Early  and  prompt  incisions  and  through-and- 
through  drainage  are  imperative.  The  drainage 
tubes  should  be  run  through  the  joint  from  one  side 
to  the  other  and  must  be  frequently  irrigated  with 
physiological  saline  solution ;  twice  daily  is  none  too 
often.  It  is  advisable  to  avoid  antiseptic  solutions, 
because  they  may  aggravate  the  inflammation, 
thereby  predisposing  to  a  resulting  ankylosis.  To 
irrigate  the  tubes  conveniently,  the  hard-rubber  tip 
of  a  Davidson  syringe  may  be  inserted  in  one  end  of 
the  drainage  tube  and  the  fluid  forced  through  into 
a  suitable  receptacle.  During  the  intervals  between 
the  irrigations  the  joint  should  be  immobilized 
and  enveloped  in  a  generous  wet  dressing.  If 
these  measures  fail  to  arrest  the  septic  process, 
the  joint  must  be  resected  or  the  limb  amputated. 

SPRAINS. 

A  sprain  is  a  violent  straining,  separation  of  the 
fibers,  or  rupture  of  one  or  more  ligaments  of  a 
joint  without  permanent  displacement  of  bone. 
Sprains  are  usually  due  to  a  wrench  or  twist  and  are 
most  common  at  the  ankle  and  wrist.  Not  in- 
frequently a  small  piece  of  bone  is  torn  off  and  the 
injury  is  then  termed  a  sprain-fracture;  these  are 
the  cases  that  are  most  often  followed  by  ankylosis. 
Although  apparently  trivial  as  a  rule,  they  should 
never  be  neglected  and  should  receive  a  gentle 
but    thorough    and    careful    examination,    because 


TRAUMATIC  INJURIES  OF  JOINTS  53 

of  the  danger  of  confusion  with  separation  of  the 
epiphysis  (in  children),  dislocation  and  fracture. 
The  nature  of  the  case  is  often  obscured  by  the 
swelling  that  is  rapidly  produced  by  the  effusion 
of  blood  and  serum  into  the  joint  and  adjacent 
tissues.  An  anesthetic  should  be  administered 
or  an  :r-ray  examination  made,  rather  than  an 
error  in  diagnosis  committed.  Laceration  or  rup- 
ture of  tendons  near  the  site  of  injury  must  not  be 
overlooked,  as  they  are  usually  responsible  for 
delayed  restoration  of  function  and  may  seriously 
cripple  the  joint  thereafter.  Rupture  of  muscular 
or  tendinous  fibers  of  the  muscles  of  the  back  is 
often  referred  to  as  a  "sprained  back"  and  occurs 
in  consequence  of  a  severe  strain  from  lifting  heavy 
weights,  or  extreme  pressure  exerted  thereon.  A 
stretching  of  the  annular  ligament  of  the  wrist 
causes  a  weakness  at  the  joint  and  is  often  spoken 
of  as  a  sprain.  Unless  every  sprain  is  accorded 
adequate  attention  and  is  treated  properly,  im- 
pairment of  function,  permanent  stiffness,  teno- 
synovitis and  even  joint  disease  may  result. 

Emergency  treatment  of  sprains  will  depend  upon 
the  severity  of  the  injury  and  the  degree  of  swelling 
already  present.  If  the  sprain  is  a  mild  one  and 
is  seen  early  before  there  is  much  subcutaneous 
effusion,  it  is  best  treated  from  the  beginning  by 
daily  gentle  massage,  especially  over  the  areas 
immediately  above  and  below  the  tender  and  in- 
flamed joint.  After  each  seance  a  wet  dressing, 
preferably  of  lead  and  opium  wash  or  aluminum 
acetate,    should   be   applied   and   use   of   the   joint 


54 


MINOR  AND  EMERGENCY  SURGERY 


should  be  encouraged.  The  exception  to  this 
generalization  is  a  recent  sprain  of  the  ankle  which, 
in  the  absence  of  swelling,  should  be  strapped  with 
strips  of  adhesive  plaster  in  the  manner  recom- 
mended by  Gibney  and  Cotterell  (Fig.  6),  and  the 
whole  covered  with  a  snugly  fitting  gauze  bandage. 


Fig.  6. — Strapping  of  sprained  ankle-joint. 

With  this  dressing  properly  applied,  the  patient 
may  be  permitted  to  walk  upon  the  foot.  Before 
applying  the  adhesive  straps  the  leg  should  be 
shaved  and  wiped  dry  and  the  foot  held  in  proper 
position  by  an  assistant  (the  foot  should  be  ducted 
toward  the  sprained  side).  One  and  a  half  inch 
wide  strips  of  adhesive  plaster  are  criss-crossed  at 


TRAUMATIC  INJURIES  OF  JOINTS  55 

right  angles  until  the  entire  joint  has  been  covered. 
The  first  starts  two-thirds  up  the  leg  on  one  side, 
close  to  the  tendo  Achilles,  crosses  the  sole  of  the 
heel  and  terminates  two-thirds  up  the  other  side 
of  the  leg.  The  next  begins  at  the  base  of  the 
little  toe  on  the  dorsal  surface  of  the  foot,  passes 
around  the  posterior  aspect  of  the  heel  and  ends 
at  the  base  of  the  great  toe.  Additional  strips  are 
applied  alternately  in  like  manner,  each  one  just 
overlapping  the  previous  one,  until  the  ankle-joint 
is  completely  included.  A  single  circular  strap 
is  then  placed  above  the  malleoli  and  another  at 
the  upper  limit  of  the  straps  on  the  leg.  This 
dressing  should  be  left  undisturbed  for  ten  days. 
To  faciliate  painless  removal  of  the  adhesive  plaster, 
it  may  be  saturated  with  oil  of  wintergreen  or  gaso- 
line. If  there  is  considerable  extravasation  when 
first  seen,  the  Gibney  strapping  should  be  deferred 
until  the  swelling  has  subsided. 

Sprains  of  a  more  severe  character  require  the 
prevention  or  reduction  of  swelling  and  immobiliza- 
tion. The  first  may  be  secured  by  the  use  of  hot, 
cold  or  anodyne  applications  and  pressure;  the 
second  by  a  sling,  splint  or  plaster-of -Paris  bandage. 
If  seen  before  much  effusion  has  occurred,  the  plaster- 
of-Paris  bandage  may  be  applied  at  once,  but  it 
should  never  be  used  in  the  presence  of  any  great 
degree  of  distention  of  the  joint.  If  much  time  has 
elapsed  and  the  joint  is  swollen,  a  cooling  applica- 
tion should  be  applied  on  gauze,  covered  with  an 
elastic  bandage,  and  the  limb  placed  in  a  sling  or 
supported  by  a  splint. 


56 


MINOR  AND  EMERGENCY  SURGERY 


A  " sprained  back"  should  be  strapped  from  below 
upward  with  strips  of  adhesive  plaster  two  inches 
wide,  from  the  third  sacral  vertebra  to  the  level  of  the 
first  lumbar  vertebra  (Fig.  7). 

After-treatment  of  Sprains. — Mild  cases  are  best 
treated  by  daily  massage  and  passive  motion,  being 


Fig.  7. — -Strapping  a  sprained  back. 

supported  during  the  intervals  without  restricting 
motion  to  such  an  extent  that  the  joint  cannot  be 
used.  The  lack  of  power  in  the  wrist  due  to  stretch- 
ing of  the  annular  ligament  is  best  overcome  by 
supporting  it  with  a  circular  leather  strap. 

Severe  cases  demand  complete  rest  and  constant 


TRAUMATIC  INJURIES  OF  JOINTS  57 

wet  dressings  until  the  greater  part  of  the  effusion  has 
been  absorbed  and  all  swelling  has  disappeared,  when 
gentle  massage,  passive  motion  and  gradual  use  of 
the  joint  may  be  introduced.  These  efforts,  however, 
should  never  be  of  sufficient  force  to  cause  pain.  The 
faradic  and  galvanic  currents  and  superheated  air 
will  also  be  found  excellent  aids,  particularly  if  there 
is  atrophy  of  the  muscles.  Usually  five  or  six  weeks 
elapse  before  there  is  complete  restoration  of  function. 
After  exceptionally  severe  sprains,  the  formation  of 
firm  adhesions  will  occasionally  so  retard  the  progress 
that  it  will  be  nesessary  to  break  them  up  forcibly 
imder  an  anesthetic. 

DISLOCATIONS. 

A  dislocation  is  a  displacement  of  the  articular 
surfaces  of  the  bones  entering  into  the  formation  of 
a  joint,  accompanied  by  rupture  of  the  joint  capsule, 
which  bones  tend  to  retain  an  unnatural  position. 
Congenital  dislocations  and  pathological  dislocations 
due  to  disease  are  not  within  the  scope  of  this  chapter 
and  tra-umatic  dislocations  only  will  be  considered. 
They  are  usually  due  to  indirect  violence  and  occur 
most  frequently  at  the  shoulder-joint.  The  capsule 
of  the  joint  is  necessarily  always  ruptured  and  if  the 
force  exerted  is  sufficient,  tendons,  muscles,  nerves, 
blood-vessels  and  even  the  skin  may  be  bruised  or 
torn.  In  general,  we  may  expect  to  find  tenderness, 
swelling,  shortening,  deformity  at  the  joint  with  pro- 
jection of  the  extremity  of  one  or  more  bones,  more 
or  less  reflex  muscular  rigidity  and  an  unatural  po- 
sition of  the  limb,  assumed  involuntarily. 


58-  MINOR  AND  EMERGENCY  SURGERY 

Examination  of  Dislocations. — A  dislocation  may  be 
simple  or  com.pound,  or  complicated  by  fracture  of 
either  the  articular  surface  or  the  shaft  of  one  or 
more  bones.  The  existing  pathological  condition 
should  be  exactly  determined  before  any  attempt  at 
reduction  is  made.  Otherwise,  irreparable  harm, 
such  as  permanent  deformity,  neiuitis,  local  paraly- 
sis, muscular  atrophy,  adhesion  of  blood-vessels  and 
nerves  to  bone  and  even  complete  ankylosis,  may 
result  from  the  surgeon's  misdirected  efforts.  Recent 
dislocations  should  be  differentiated  from  ancient 
dislocations.  The  latter  are  often  misleading  be- 
cause the  joint  cavity  may  be  entirely  obliterated  by 
adhesions  and  they  often  present  a  spurious  form  of 
crepitus,  due  to  organized  effusion  in  the  surrounding 
tissues.  The  limb  may  atrophy  from  lack  of  use  and 
if  the  injury  is  neglected  for  a  sufficiently  long  time, 
a  false  joint  not  infrequently  results.  If  the  first 
attempt  at  reduction  fails,  palpation  under  anes- 
thesia and  the  r^c-ray  should  always  be  employed  to 
establish  positively  an  accurate  diagnosis  and  fa- 
cilitate manipulation.  It  is  of  the  utmost  importance 
to  note  whether  or  not  the  head  of  the  bone  rotates 
with  the  shaft;  if  it  does  not,  there  is  probably  a 
fracture  near  the  epiphysis.  In  the  presence  of  an 
impacted  fracture  of  the  neck  of  the  bone,  however, 
the  head  will  rotate  with  the  shaft. 

Dislocations  of  the  jaw  should  not  be  confounded 
with  a  fracture  at  the  neck  of  the  condyle.  In 
fracture  there  is  mobility,  while  a  dislocation  is  im- 
mobile. 

Dislocations    at    the  shoulder- joint   are  the  most 


TRAUMATIC  INJURIES  OF  JOINTS  59 

common  of  all,  and  the  proximity  of  the  brachial 
vessels  and  nerves  renders  a  correct  diagnosis  of 
special  importance.  In  subcoracoid  dislocation  the 
elbow  cannot  be  made  to  touch  the  side  of  the  chest, 
with  the  hand  on  the  opposite  shoulder ;  while  if  the 
fingers  cannot  touch  the  space  beneath  the  acromion 
process,  a  fracture  has  probably  occurred.  A  dis- 
location does  not  tend  to  recur  after  reduction.  In 
most  fractures  it  is  extremely  difficult  to  maintain 
proper  position  of  the  fragments.  In  subclavicular 
and  subglenoid  dislocations  there  is  more  abduction 
of  the  arm  and  more  tension  on  the  skin.  Sub- 
acromial and  subspinous  dislocations  are  posterior 
displacements  and  the  position  assumed  by  the  arm 
is  the  reverse  of  anterior  dislocations :  adduction  and 
inward  rotation.  Luxatio  erecta  and  supracoracoid 
dislocations  are  extremely  rare  and  easily  reduced. 

Dislocations  at  the  elbow  are  more  common  in 
early  life  and  the  diagnosis  is  usually  easy.  There 
may  be  backward  dislocation  of  the  radius  and 
ulna,  forward  dislocation  of  the  radius  and  ulna 
(usually  complicated  by  fracture  of  the  olecranon), 
lateral  dislocations,  or  dislocation  of  the  radius  for- 
ward (commonly  associated  with  fracture  of  the 
ulna) . 

Backward  dislocations  of  the  thumb  are  often 
complicated  by  the  anterior  ligament  or  the  flexor 
tendons  slipping  between  the  two  bones  and  are 
then  extremely  difficult  to  reduce. 

Dislocations  of  the  hip  are  relatively  uncommon, 
but  it  is  important  to  distinguish  between  dorsal 
and  anterior  dislocations.     In  dorsal,  or  posterior. 


6o  MINOR  AND  EMERGENCY  SURGERY 

dislocations  there  is  flexion,  adduction,  inversion, 
shortening,  and  the  head  of  the  femur  lies  above 
Nelaton's  line.  These  symptoms  are  more  marked 
in  dislocations  on  the  ilium  than  when  the  head  of 
the  bone  lies  in  the  sciatic  notch.  Anterior  dislo- 
cations are  either  pubic  or  obturator  (thyroid). 
In  the  former  the  thigh  is  abducted  and  everted, 
the  hip  is  flattened  and  the  prominence  of  the 
great  trochanter  disappears,  and  there  is  some 
shortening.  In  the  latter  variety  there  is  also 
flattening  and  aversion,  but  there  is  lengthening 
instead  of  shortening.  In  all  anterior  dislocations 
of  the  thigh  the  legs  cannot  be  approximated. 
Dislocations  are  easily  differentiated  from  fractures 
in  this  region,  but  the  possibility  of  a  fracture  occur- 
ring simultaneously  should  be  borne  in  mind.  In  such 
instances  it  is  better  to  consider  the  injury  as  a  frac- 
ture than  as  a  dislocation,  as  attempts  to  reduce  the 
dislocation  usually  fail.  Supracotyloid,  infracoty- 
loid  and  perineal  dislocations  are  anomalous  va- 
rieties, occurring  very  rarely  and  are  reduced  with- 
out difficulty. 

Treatment  of  Dislocations. — ^Having  established  the 
diagnosis  of  a  dislocation,  the  treatment  should  be 
instituted  promptly,  as  a  profuse  extravasation  of 
serum  and  blood  into  the  injured  area,  which 
increases  as  time  elapses,  may  seriously  interfere 
with  our  efforts  at  reduction  and  complicate  the 
result.  The  treatment  may  be  said  to  consist  of: 
(i)  reduction  (restitution  of  the  displaced  parts  to 
their  normal  relationship) ,  (2)  retention  (prevention 
of  recurrence),  and  (3)  restoration  of  function.     The 


TRAUMATIC  INJURIES  OF  JOINTS  6i 

first  maysbe  accomplished  by  manipulation,  manipu- 
lation plus  anesthesia,  extension  and  counter- 
extension,  or  arthrotomy ;  the  second  by  the  appli- 
cation of  a  suitable  dressing,  firmly  fixing  the  parts 
in  their  normal  position ;  and  the  third  by  massage, 
passive  motion,  hot  air  and  electricity. 

Simple  forcible  manipulations  are  quite  often 
sufficient  to  effect  a  complete  reduction,  but  when 
the  first  attempt  fails  recourse  to  other  methods 
should  be  considered.  The  obstacles  to  reduction 
usually  encountered  are  :  (i)  reflex  muscular  rigidity, 
(2)  voluntary  muscular  opposition,  (3)  a  small  rent 
in  the  capsule  and  (4)  interposition  of  a  fragment  of 
the  capsule,  nerves,  fascia,  or  some  other  soft  struc- 
ture. Of  these,  muscular  rigidity  is  the  most 
common  and  may  easily  be  eliminated  by  general 
anesthesia,  pushed  to  complete  muscular  relaxa- 
tion. Ether  is  the  safest  anesthetic  for  this 
purpose.  The  relaxation  afforded  by  the  first  stage 
of  anesthesia  may  seem  sufficient  to  permit  reduc- 
tion, but  it  must  be  remembered  that  the  patient 
will  still  be  conscious  of  the  pain  produced  by  the 
manipulations  and  dangerous  shock  may  be  occa- 
sioned thereby.  Manifestly,  it  is  better  to  wait 
for  complete  surgical  anesthesia.  Extension  and 
counter-extension  by  means  of  weights,  pulleys,  the 
Spanish  windlass,  etc.,  have  been  advocated  by 
some  surgeons  as  a  satisfactory  method  of  enforcing 
reduction,  but  with  the  exception  of  gradual  traction, 
the  danger  of  injury  to  the  soft  parts  is  so  great 
under  such  circumstances  that  the  risk  is  not 
worth  the  attempt.     Serious  laceration  or  rupture  of 


62  HI  I  NOR  AND  EMERGENCY  SURGERY 

the  soft  structures  not  infrequently  follows,  because 
the  force  exerted  cannot  be  accurately  estimated. 
When  a  small  rent  in  the  capsule  or  the  interposition 
of  soft  parts  interferes  with  proper  reduction,  or  a 
blood-vessel  or  nerve  has  been  ruptured,  an  open 
arthrotomy  at  the  earliest  possible  moment  is  the 
desirable  procedure.  No  surgical  operation  should 
be  performed  under  more  rigid  aseptic  circumstances 
than  an  arthrotomy,  because  of  the  susceptibility  of 
all  synovial  membranes  to  infection.  Having  opened 
the  joint,  temporary  enlargement  of  the  rent  in  the 
capsule  and  reposition  of  the  articular  surfaces  are 
easy.  Severed  arteries,  veins  and  nerves  should  be 
carefully  ligated  or  sutured  in  the  usual  manner. 
Ancient  dislocations  nearly  always  require  an  anes- 
thetic in  order  that  the  adhesions  may  be  broken  up 
before  the  attempt  to  effect  reduction  is  made.  Gen- 
erally, however,  an  open  operation  is  to  be  preferred 
because  the  danger  of  laceration  of  the  displaced 
stuctures  is  otherwise  so  great,  owing  to  their  changed 
relations.  Complicated  dislocations  should  also  re- 
ceive the  benefit  of  accurate  manipulation,  afforded 
by  an  arthrotomy  only. 

Having  effected  a  satisfactory  reduction,  recur- 
rence of  the  dislocation  may  be  prevented  by  means 
of  a  firm  dressing  fixing  the  parts  in  their  normal, 
positions.  This  may  consist  of  a  bandage  or 
plaster-of -Paris  support,  superimposed  upon  a  wet 
dressing  if  there  is  much  effusion. 

Torn  ligaments  usually  heal  in  about  three  weeks 
and  it  is  then  safe  to  commence  massage  and  pas- 
sive  motion.     They   should   preferably   be   carried 


TRAUMATIC  INJURIES  OF  JOINTS  63 

out  by  the  surgeon,  in  order  that  the  daily  dose 
may  be  regulated  satisfactorily.  Applications  of 
the  faradic  current  will  also  be  found  a  valuable 
aid  in  these  conditions. 

A  displaced  coccyx  with  resulting  coccygodynia 
is  an  exceedingly  painful  and  annoying  condition; 
coccygectomy  only  will  give  relief. 

Ankylosis  is  not  due  to  immobilization,  but  to 
inflammation  and  its  products.  If  forcible  motion 
causes  pain,  the  ankylosis  is  fibrous  in  character; 
if  no  pain  is  produced,  it  is  bony.  The  former 
is  best  treated  by  forced  motion,  either  with  or 
without  an  anesthetic,  or  gradual  traction.  The 
pain  following  these  manipulations  should  not  last 
longer  than  an  hour  or  two ;  if  it  does,  harm  is  being 
done.  Bony  ankylosis  necessitates  an  open  opera- 
tion and  the  removal  of  a  wedge-shaped  piece  of 
bone. 


CHAPTER  IV. 
SIMPLE  FRACTURES. 

Simple  fractures  are  closed  fractures  having  no 
communication  with  the  exterior.  They  may  result 
in  two  fragments  only,  or  several  (comminution). 
Epiphyseal  separations,  green-stick,  fission  and 
depressed  fractures  are  anomalous  varieties.  In  no 
other  class  of  injuries  is  accurate  diagnosis  and 
exact  treatment  of  such  paramount  importance, 
because  every  patient  that  has  sustained  a  fracture 
will  become  an  ambulatory  example  of  the  surgeon's 
ability  and  skill,  or  his  limitations  and  incapability. 
Also,  these  cases  are  frequently  the  basis  of  a  mal- 
practice suit.  Every  detail  contributing  to  the 
complete  anatomical,  cosmetic  and  functional  re- 
covery of  the  injured  part  should  receive  careful 
consideration,  and  the  patient  should  always  be 
immediately  informed  of  the  probable  result.  Strict 
obedience  to  orders  must  be  insisted  upon,  in  order 
that  the  patient  may  do  nothing  that  might  jeopard- 
ize his  best  interests. 

Examination  of  Fractures. — All  fractures  should 
be  examined  as  early  as  possible,  since  extravasation 
into  the  injured  area  may  obscure  a  gieat  deal  of 
valuable  information.  The  patient's  general  con- 
dition is  always  of  great  importance;  the  bodily 
nourishment  and  development,  the  condition  of 
the  pupils  and  their  reaction,  partial  or  complete 

64 


SIMPLE  FRACTURES  65 

unconsciousness,  the  degree  of  shock  present  and 
the  occurrence  of  other  complications  and  injuries 
should  be  carefully  noted.  Thorough  investigation 
will  disclose  whether  a  fracture  is  simple  or  com- 
pound or  complicated,  complete  or  incomplete,  and 
the  line  of  fracture.  The  nature  of  the  displace- 
ment will  necessarily  depend  upon  the  line  or  lines 
of  fracture  and  the  action  of  various  muscles. 

On  inspection,  any  muscular  spasm,  deformity, 
swelling  or  discoloration  are  observed,  and  the 
contour  of  an  injured  limb  compared  with  that  of  its 
fellow.  Palpation  must  be  exceedingly  careful  and 
gentle,  to  avoid  causing  pain  or  injury  to  the  adja- 
cent structures,  but  preternatural  mobility  and  crep- 
itus must  be  diligently  searched  for.  In  those  in- 
stances, however,  where  the  nature  of  the  injury  is 
obvious,  it  is  cruel  and  unnecessary  to  twist  the  site 
of  fracture  about  simply  to  elicit  crepitus  and,  in  ad- 
dition, forcible  movements  tend  to  damage  the  soft 
parts  and  increase  extravasation.  Mensuration  is 
also  of  great  value  for  the  determination  of  the  ex- 
act extent  of  displacement.  Loss  of  function  and 
subjective  pain  are  usually  self-evident  and  are 
important  S3rmptoms.  AH  obscure  cases  and  frac- 
tures near  joints  should  be  examined  under  anesthe- 
sia, as  well  as  those  occurring  in  children  and  nervous 
individuals.  The  :r-ray  is  of  inestimable  service 
for  the  definite  location  of  a  suspected  fracture 
and  for  confirmation  of  a  diagnosis.  It  should  be 
remembered  that  a  radiograph  taken  from  the 
anterior  or  lateral  aspect  alone  is  likely  to  deceive, 
and  the  x-ray  examination  should  therefore  always 
5 


66       -      MINOR  AND  EMERGENCY  SURGERY 

include  both  an  antero-posterior  and  lateral  view. 
An  x-TSLj  photograph,  also,  is  much  more  reliable 
than  a  simple  fluoroscopic  examination. 

The  two  most  constant  errors  in  diagnosis  are 
mistaking  a  pre-existing  deformity  for  a  recent 
fracture  and  confusing  joint  crepitus  with  that  of 
a  fracture.  The  inexperienced  may  be  misled  by 
the  crepitus  due  to  calcareous  deposits  in  the  joints 
or  teno-synovitis,  and  conversely,  the  interposition 
of  muscle  or  fascia  between  the  fragments  may 
eliminate  crepitus.  When  dealing  with  children, 
special  care  should  be  exercised  to  differentiate 
separation  of  an  epiphysis  from  a  true  fracture. 
Simple  fractures  are  often  accompanied  by  more 
or  less  aseptic  fever  and  shock.  This  fever  must 
be  distinguished  from  that  of  sepsis,  which  signifies 
complications.  The  increased  leucocytosis  present 
in  sepsis  is  a  reliable  diagnostic  guide  and  is  usually 
sufficient  to  differentiate. 

Emergency  treatment  of  fractures  consists  only  of 
those  measures  that  will  make  the  patient  temporar- 
ily comfortable  and  prevent  further  injury,  although 
most  fractures  of  the  upper  extremity  and  thorax 
may  be  dressed  immediately.  Since  by  the  very 
nature  of  these  emergency  fractures  they  cannot  be 
accurately  catalogued,  the  extent  of  advisable  in- 
vestigation and  manipulation  must  be  left  to  the 
surgeon's  discretion.  Clothing  should  be  removed, 
being  cut  or  torn  away  if  necessary,  any  marked  de- 
formity reduced  and  the  limb  placed  in  a  suitable 
position.  The  site  of  injury  may  be  covered  with  a 
wet  gauze  dressing  and  the  entire  part  supported 


SIMPLE  FRACTURES  67 

with  splints  lined  with  cotton  or  oakum.  For  se- 
curity, splints  are  best  fixed  with  adhesive  plaster 
before  bandaging.  All  precautions  should  be  taken 
that  rough  or  careless  manipulations  do  not  convert 
a  simple  into  a  compound  or  complicated  fracture. 
If  the  patient  is  in  severe  pain,  one-quarter  of  a  grain 
of  morphine  may  be  administered  hypodermatically. 
Alcohol  and  other  stimulants  are  contra-indicated. 

Permanent  Dressing  of  Fractures. — All  fractures 
are  advantageously  reduced  as  early  as  possible, 
except  when  the  extravasation  and  tension  are  ex- 
treme. Under  such  circumstances  manipulations 
are  dangerous  and  it  is  better  merely  to  place  the 
limb  in  a  comfortable  position  and  surround  it  with 
sand  bags,  until  the  wet  dressing  has  reduced  the 
swelling.  Having  accomplished  reduction  of  the 
fracture,  we  have  at  our  disposal  four  methods  of 
treatment  for  simple  fractures:  (i)  immobilization 
by  splints  and  bandages,  (2)  fixation  by  extension, 
(3)  immobilization  plus  massage  and  (4)  open  opera- 
tion, each  of  which  has  distinct  value  in  selective 
cases. 

Splints  may  be  made  of  wood,  wire,  metal,  starch, 
or  any  other  light  and  rigid  material.  Whenever 
practical,  moulded  plaster-of-Paris  splints  will  be 
found  the  most  servicable.  This  does  not  necessarily 
imply  complete  encasing  of  the  injured  part,  but  one 
section  of  several  turns,  back  and  forth,  of  the  re- 
quired width  and  length  moulded  on  the  anterior 
half,  and  another  similar  section  moulded  to  the 
posterior  half  of  the  injured  part ;  when  firm,  they  are 
bandaged  together.     A  plaster  dressing  should-  al- 


68      ■      MINOR  AND  EMERGENCY  SURGERY 

ways  include  the  proximal  and  distal  joints  from  the 
seat  of  injury,  and  by  beginning  the  underlying 
gauze  bandage  at  the  distal  extremity  of  the  limb, 
annoying  edema  will  be  eliminated.  The  same 
rules  apply  to  splints  of  any  other  substance. 

Fixation  by  extension  is  most  often  utilized  for 
fractures  of  the  lower  extremity,  and  all  joints  below 
the  fracture  are  included  in  the  dressing.  The  steps 
in  applying  an  improvised  extension  apparatus  are: 

I.  Cut  an  appropriately  wide  strip  of  adhesive 
plaster  of  sufficient  length  to  leave  a  loop  projecting 
four  or  five  inches  below  the  heel. 


Fig.  8. — Improvised  extension  apparatus. 

2.  Place  an  oblong  piece  of  wood  about  one-quarter 
of  an  inch  thick  in  the  site  of  the  loop  on  the  sticky 
side  of  the  plaster,  and  punch  a  hole  through  the 
center. 

3.  Knot  a  piece  of  heavy  cord  and  run  it  through 
the  perforation,  with  the  knot  on  the  inside  (Fig.  8) . 

4.  Apply  the  plaster  laterally  to  both  sides  of  the 
leg  (Fig.  9)  and  fix  with  a  firm  gauze  bandage,  in- 
cluding the  toes. 

5.  Reduce  the  fracture  and  have  an  assistant  main- 
tain constant  traction. 

6.  Fix  an  ordinary  wooden  spool  horizontally  at 


SIMPLE  FRACTURES 


69 


the  foot  of  the  bed  at  a  level  that  will  slightly  elevate 
the  limb. 

7.  Attach  the  necessary  weights  (usually  about 
eight  pounds)  to  the  free  end  of  the  cord. 

8.  Apply  coaptation  splints  to  the  site  of  the  frac- 
ture. They  are  preferably  lined  with  cotton  and 
secured  with  adhesive  plaster. 

9.  Pad  the  entire  limb  with  cotton  and  bandage 
two  lateral  splints  the  whole  length  of  the  extremity. 


Fig.  9. — Improvised  extension  apparatus  applied. 


Even  though  daily  massage  is  selected  as  the 
method  of  treatment  in  a  given  instance,  the  in- 
jured part  must  be  supported  with  splints  during  the 
intervals.  The  field  of  this  procedure  is  limited  to 
CoUes'  fractures  and  single  transverse  fractures,  since 
in  all  other  fractures  accurate  approximation  cannot 
be  maintained  without  constant  external  support. 
The  results  in  appropriate  cases,  however,  have  been, 
most  satisfactory. 

Open  operation  on  simple  fractures  has  recently 
been  widely  practised  and  recommended,  on  the 
ground  that  it  assures  a  more  exact  appoximation 
of  the  fragments  than  any  other  method  of  treat- 


70      -      MINOR  AND  EMERGENCY  SURGERY 

ment.  In  opposition  to  this  reasoning,  it  must  be 
remembered  that  tight  suturing  establishes  such  con- 
ditions of  leverage  that  the  maintenance  of  precise 
adjustment  is  at  best  uncertain,  repair  is  slower,  and 
we  must  still  depend  largely  upon  external  support. 
While  admitting  that  the  risk  of  infection  is  a  nega- 
tive quantity,  in  view  of  modern  surgical  technic, 
operative  measures  are  positively  indicated  in  simple 
fractures  only  when  approximation  and  union  are 
obstructed  by  the  interposition  of  soft  structures,  or 
the  fragments  are  irreducible,  and  when  good  position 
cannot  be  obtained  by  manipulation.  Since  opera-, 
tive  measures  convert  a  simple  fracture  into  a  com- 
pound fracture,  further  discussion  will  be  omitted 
here. 

The  following  facts  are  worth  remembering: 

The  x-rsiy  is  of  great  value,  not  only  for  diagnosis 
but  also  for  confirmation  of  good  position  of  the 
fragments  after  reduction. 

An  anesthetic  will  overcome  muscular  opposition. 

The  recumbent  position  in  the  aged  tends  to  induce 
hypostatic  pneumonia;  at  least  a  semi-erect  position 
should  be  insisted  upon. 

A  great  deal  of  unsuspected  contusion  and  .sub- 
cutaneous extravasation  may  become  manifest  dur- 
ing the  first  week  or  ten  days. 

The  longer  a  fracture  remains  imreduced  the 
greater  will  be  the  muscular  rigidity. 

Gravity  must  be  counterbalanced  so  that  position 
will  assist  restitution. 

All  fracture  dressings  should  exert  uniform  pressure 
throughout  their  entire  length. 


SIMPLE  FRACTURES  71 

A  dressing  applied  too  loosely  will  permit  motion 
of  the  fragments,  while  if  applied  too  tightly  it  will 
interfere  with  the  circulation. 

Apply  coaptation  splints  to  the  site  of  all  fractures 
treated  by  extension. 

Contused  areas  should  not  be  covered  with  plaster- 
of -Paris. 

Morphine  should  not  be  given  to  patients  wearing  a 
plaster  cast,  because  the  pain  due  to  the  faulty  po- 
sition of  an  ill-fitting  cast  or  pressure  sores  can  be 
endured  when  morphine  is  given,  although  the  cast 
should  be  removed. 

No  attempt  should  be  made  to  break  up  an  im- 
paction if  the  fragments  are  in  good  alignment. 

An  epiphyseal  separation  is  analogous  to  a  trans- 
verse fracture. 

Correct  the  deformity  of  a  green-stick  fracture  so 
that  it  does  not  tend  to  recur. 

FRACTURES  OF  THE  SKULL. 

Those  of  the  vault  may  occur  as  fissure,  pene- 
trating, depressed  or  bursting  fractures.  There  may 
be  a  linear  fracture  of  the  external  table  only  when 
the  inner  table  is  extensively  splintered,  because  the 
latter  is  thinner  and  more  brittle  and  the  diploe 
distributes  the  force  over  a  wider  area.  Depressed 
fractures  are  invariably  associated  with  brain  injury 
and  practically  all  fractures  of  the  skull  are  accom- 
panied by  some  s^^mptoms  of  cerebral  concussion, 
laceration  or  compression.  These  are  the  danger 
signals,  since  injuries  to  the  brain  and  its  membranes 
may  terminate  in  meningeal  hemorrhage,  meningitis, 


72       ^      MINOR  AND  EMERGENCY  SURGERY 

encephalitis  or  cerebral  abscess.  Infection  and 
necrosis  due  to  insufficient  drainage  and  loose  frag- 
ments are  also  serious  consequences.  In  fracture 
by  contre-coup,  as  the  name  indicates,  the  fracture 
is  on  the  other  side  of  the  head ;  opposite  to  the  site 
of  injury.  Although  the  diagnosis  of  fractures  of 
the  skull  may  be  easy,  it  often  taxes  our  diagnostic 
acumen.  Fissures,  depressions,  mobility,  crepitus 
and  local  pain  and  tenderness  should  be  diligently 
searched  for  and  the  functional  integrity  of  the  brain 
and  nerves  ascertained.  Explorative  incision  is  of 
the  utmost  value  as  a  diagnostic  aid.  Wh.en  a 
fracture  is  suspected  but  not  demonstrable,  the 
scalp  should  be  freely  incised  and  the  skull  tre- 
phined. This  will  permit  inspection  of  the  inner 
table  and  dura.  The  brain  may  be  explored,  if 
necessary,  by  incising  the  dura  and  using  a  probe. 
By  so  doing,  the  underlying  conditions  can  be 
ascertained  and  no  errors  of  omission  will  be  made. 

Fractures  at  the  base  may  involve  the  anterior, 
middle  or  posterior  fossa,  and  the  latter  are  graver 
because  of  the  proximity  to  the  medulla.  In  addi- 
tion to  cerebral  symptoms,  these  fractures  are  usu- 
ally evidenced  by  hemorrhage  behind  the  eye,  from 
the  nose,  into  the  pharynx,  or  from  or  behind  the 
ear,  or  by  indications  of  injury  to  nerve  trunks.  Not 
infrequently  the  cranial  nerves  are  damaged  and 
cerebro-spinal  fluid  or  even  fragments  of  brain  tissue 
may  escape  from  the  nose  or  ear. 

The  tables  on  pp.  74-77  are  intended  to  illustrate 
the  differential  diagnosis  of  head  injuries  associated 
with  brain  injury.     An  alcoholic  odor  to  the  breath 


SIMPLE'  FRACTURES  73 

is  of  no  diagnostic  significance  whatever,  because 
some  well-intending  by-stander  will  often  give  whiskey 
or  brandy  to  an  injured  person,  before  the  surgeon's 
arrival,  and  the  fact  that  a  person  is  intoxicated  is 
no  proof  that  his  skull  is  not  fractured. 

The  prognosis  is  uncertain:  about  75  per  cent,  of 
fractures  of  the  vault  and  50  per  cent,  of  fractures 
of  the  base  recover.  A  common  sequel  is  sun- 
stroke, occurring  at  the  next  exposure  to  intense 
heat,  and  these  patients  should  be  instructed  accord- 
ingly. 

The  following  suggestions  are  applicable  to  all 
severe  injuries  of  the  head: 

Confine  the  patient  to  bed. 

Avoid  cardio-vascular  stimulation,  especially  hy- 
podermic injections. 

Shave  the  injured  area  or  the  entire  scalp. 

Apply  an  ice  cap. 

Secure  free  movements  of  the  bowels. 

Keep  the  room  dark  and  absolutely  quiet. 

Good  nursing  and  constant  careful  observation  are 
items  of  the  utmost  importance.  Stimulants  are 
dangerous  because  they  increase  arterial  tension,  al- 
though in  exceptional  instances  they  are  required  to 
combat  shock,  but  even  under  such  circumstances 
they  should  be  withdrawn  as  rapidly  as  the  existing 
conditions  will  permit.  Croton  oil  is  the  most  sat- 
isfactory purgative  as  it  acts  quickly  and  lessens 
blood  pressure.  Two  or  three  drops  may  be  placed 
on  the  patient's  tongue,  or,  if  he  is  unconscious,  it 
may  be  administered  in  an  enema  of  olive  oil,  con- 
taining four  or  five  drops  of  croton  oil.     A  simple 


74- 


MINOR  AND  EMERGENCY  SURGERY 


General 
Appearance 

Appearance  of 
the  Injury 

Unconsciousness 

Pupils 

Scalp 
Wounds. 

Normal 

Bone  may  be  ex- 
posed,   but    nor- 
mal skull  sutures 
can     be      wiped 
clean.       No  per- 
sistent   red    line 
of     hemorrhage. 
The     hematoma 
never  pulsates. 

Conscious 

Normal. 
Equal  and  re- 
act promtly. 

Alcoholic 
Poisoning. 

Bloated. 
Lips      livid. 
Red     face 
and   nose. 

No    evidence    of 
injury. 

May  be  momen- 
tarily      aroused 
by  inhaling  am- 
monia  or    pres- 
sure on    the  su- 
praorbital nerve. 

Generally  di- 
lated,     but 
active.    Re- 
act to  light. 

Cerebral 
Concussion. 

Face  pale  . .  . 

N  o     manifesta- 
tions of  injury, 
or    at    most    a 
simple  fissure 
fracture. 

S  e  m  i-unconsci- 
ousness.       Mind 
weak    and    con- 
fused,   but     not 
abolished.       Oc- 
casionally total- 
ly unconscious. 

Variable. 
React  to 
light.    Eye- 
lids     some- 
what open. 

SIMPLE  FRACTURES 


75 


Pulse 

Respira- 
tion 

Stomach, 

Bowels,  and 

Bladder 

Coma 

Convul- 
sions 

Mental,  Motor, 
and  Sensory 
Disturbances 

Normal,. .  . 

Normal. .  . 

Negative 

Absent. 

Absent. 

Absent. 

Full      and 
soft. 

Deep,  slow 
and  ster- 
torous. 

May  be  vomit- 
ing. 

Possibly 
gradual. 

Do 

Mental  dullness 
and  motor 
weakness.  Inco- 
ordination o  f 
muscles. 

Small, 
rapid  and 
intermit-, 
tent. 

Quiet. 
Shallow 
and    ir- 
regular. 

Vomiting    after 
recovery  of  con- 
sciousness .     In- 
voluntary     de- 
fecation      and 
micturition     at 
times. 

Tempo- 
rary. 

Do 

Mentally  depress- 
ed. Occasional 
delirium.  Tem- 
perature s  u  b  - 
normal,  gradu- 
ally rising  as  re- 
action occurs. 

76^ 


MINOR  AND  EMERGENCY  SURGERY 


General 
Appearance 

Appearance  of 
the  Injury 

Unconsciousness 

Pupils 

Pace     pale. 
Expression 
vacant. 

Do 

Temporary 

Contusion 

(severe 

concussion). 

what  sensi- 
ble to  light. 

Cerebral 
Laceration. 

Face       pale. 
Skin    cold. 
Profuse 
p  e  r  s  p  i- 
ration. 

Usually  evidence 
of  fracture. 

More  prolonged; 
followed  by  irri- 
t  a  b  i  1  i  t  y  and 
restlessness. 

Do. 

Cerebral 

Compres- 
sion. 

Face      pale. 
Skin  cold. 

Usually     de- 
pressed   frac- 
ture.    Hema- 
toma    pulsates. 
May  be  due  to 
concealed  hem- 
orrhage, in  the 
absence  of  frac- 
ture. 

Comes  on  imme- 
diately   when 
due      to      bone 
pressure;    grad- 
u  a  1      develop- 
ment of  symp- 
toms when  due 
to   hemorrhagic 
pressure.  Tends 
to  progress. 

Remain  fix- 
ed.    One  or 

both  may 
be  dilated 
or  contract- 
ed. Do  not 
react  to 
Hght.  Eye- 
lids -  closed. 

SIMPLE  FRACTURES 


77 


Pulse 

Respira- 
tion 

Stomach, 

Bowels  and 

Bladder 

Coma 

Convul- 
sions 

Mental,  Motor, 
and  Sensory 
Disturbances 

Feeble  and 

Do 

Do 

Do 

Do 

Power    of    move- 
ment not  destroy- 
ed.    Mentally 
depressed,    plus 
shock    and    gen- 
eral depression. 

irregular. 

Do 

Do 

Do 

Do 

0  c  c  a  - 
sional. 

Mental  irritabil- 
ity. Hemiplegia, 
if  motor  areas 
are  injured. 
Legs  and  arms 
flexed.  Lasts 
some  days. 

Slow, 
(s  o  m  e- 
times  40- 
60)    and 
full. 

Labored 
and  ster- 
torous. 

Stomach  insen- 
sible,   even     to 
emetics.  Bowels 
torpid, 

Lasts  as 
long  as 
pres- 
sure 
exists. 

Do 

Partial  or  com- 
plete paralysis. 
Special  senses 
entirely  sus- 
pended. 

78^  MINOR  AND  EMERGENCY  SURGERY 

fissure  fracture  without  depression  of  bone  or  brain 
symptoms  will  require  no  additional  treament.  All 
depressed  and  pimctured  fractures  and  those  ex- 
hibiting symptoms  of  brain  injury  demand  immediate 
operation.  The  skull  should  be  trephined  and  the 
depressed  fragments  elevated  and  cleansed  or  re- 
moved. Any  piece  of  bone  with  good  periosteal 
attachments  will  not  become  necrotic  and  should  be 
left  in  situ.  If  there  is  hemorrhage  from  the  dura, 
the  bleeding  vessel  must  be  ligated,  while  if  it  origi- 
nates in  the  brain  proper  or  follows  the  removal  of 
bone  fragments  the  wound  should  be  packed  with 
narrow  strips  of  sterile  gauze.  Provision  for  drainage 
is  essential  in  all  these  cases. 

In  fractures  of  the  base  with  hemorrhage  or  ex- 
udation from  the  nose  or  ear  these  cavities  should 
be  wiped  clean  with  a  little  moist  cotton  on  an  appli- 
cator and  loosely  plugged  with  sterile  cotton,  which 
should  be  changed  as  often  as  it  becomes  saturated. 
Irrigations  are  dangerous  as  they  may  carry  infection 
into  the  fissures.  In  addition  to  these  measures,  the 
treatment  is  symptomatic. 

In  gunshot  fractures  of  the  skull  the  bullet  should 
be  removed  if  reasonably  accessible,  as  the  mortality 
is  considerably  greater  if  the  bullet  is  permitted  to 
remain.  Nevertheless,  it  is  sometimes  wiser  to  leave 
a  harmless  bullet  in  the  tissues  than  to  perform  an 
extensive  and  destructive  operation  for  its  removal. 

FRACTURES  INVOLVING  THE  NOSE  AND  MOUTH. 

The  cardinal  principle  in  the  treatment  of  these 
fractures  is  cleanliness.     The  cosmetic  result  is  of 


SIMPLE  FRACTURES  79 

great  importance  so  that  exact  adjustment  and  firm 
fixation  by  means  of  splints  or  operative  procedures 
at  the  earliest  possible  moment  is  imperative.  In 
fractures  of  the  nose  the  mucous  membrane  should 
be  cocainized  and  cleansed  with  a  little  sterile  cot- 
ton on  a  probe.  Hemorrhage  is  controlled  by  in- 
jections of  ice  water,  applications  of  adrenalin  chloride 
(i-iooo)  or  packing  with  gauze  strips.  The  fracture 
may  be  reduced  and  proper  position  of  the  fragments 
maintained  by  elevating  the  spicules  with  a  director 
and  introducing  an  Asch's  or  Coleridge's  splint,  if 

5  inches 


Bend__ 
Here 


Fig.  10. — Cardboard  cut  for  cup-shaped  splint  for  lower  jaw. 

necessary.  Fractures  of  the  superior  maxilla  usually 
require  instrumental  reposition  of  the  fragments, 
suturing  and  drainage.  Little  or  no  tissue  need  be 
removed,  because  of  the  vascularity  of  this  region. 
In  fractures  of  the  lower  jaw,  a  cup-shaped  splint  and 
a  Barton  bandage  are  often  all  that  will  be  necessary. 
To  apply  this  dressing: 

1.  Cut  a  piece  of  cardboard  of  appropriate  size, 
as  shown  in  Fig.  10. 

2.  Steam  over  boiling  water. 


8o 


MINOR  AND  EMERGENCY  SURGERY 


3.  Mould  to  the  chin  and  line  with  cotton. 

4.  Begin  a  2  1/2  inch  wide  muslin  bandage  diag- 
onally at  the  vertex  of  the  head,  bring  down  on  one 
side  of  the  face,  under  the  jaw,  up  the  other  side, 
across  the  starting-point,  down  around  the  occiput, 
across  the  anterior  surface  of  the  jaw,  around  the 


Fig.  II. — Barton  bandage  applied. 


other  side  of  the  occiput  and  up  to  the  starting-point. 
This  is  really  a  double  figure-of-eight  bandage 
(Fig.  II). 

5.  Re-apply  the  dressing  every  two  or  three  days. 

In  severe  cases,  or  whenever  this  dressing  is  in- 
adequate, recourse  may  be  had  to  an  interdental 


SIMPLE  FRACTURES  8i 

splint  or  wiring  of  the  teeth.  Open  operation  and 
wiring  of  the  bone  fragments  is  to  be  avoided  if 
possible,  because  of  the  great  danger  of  necrosis  and 
sepsis  therefrom.  Where  the  damage  is  extensive, 
dental  prosthesis  is  of  considerable  aid  to  the  surgeon. 
Talking  and  mastication  must  be  interdicted,  the 
mouth  washed  out  with  a  mild  antiseptic  every  two 
hours  and  immediately  after  eating  and  the  teeth 
kept  scrupulously  clean.  The  diet  should  be  entirely 
liquid  and  administered  through  a  tube. 

FRACTURES  OF  THE  RIBS  AND  SPINE. 

Fractured  ribs  are  best  treated  by  strapping  with 
strips  of  adhesive  plaster  from  below  upward,  be- 
ginning at  the  spine  and  ending  at  the  sternum,  on 
the  affected  side  only.  Surgical  emphysema  occa- 
sionally accompanies  these  fractures  and  is  of  no  im- 
portance. Pneumonia,  on  the  contrary,  is  a  serious 
complication  and  the  patient  should  be  guarded 
accordingly.  It  will  not  be  amiss  to  give  all  patients 
with  fractured  ribs  a  sedative  cough  mixture. 

Fractures  of  the  spine  involving  the  neural  arch 
only  and  without  displacement  are  uncommon.  The 
usual  fracture  is  really  a  fracture  dislocation  and  is 
almost  invariably  accompanied  by  compression  or 
injury  of  the  cord,  caused  by  bone  fragments  or 
hemorrhage.  If  due  to  the  latter,  the  resulting 
paralysis  is  more  gradual.  The  evidences  of  cord 
injury  are:  (i)  profound  shock,  (2)  partial  or  com- 
plete motor  and  sensory  paralysis,  corresponding  to 
the  point  of  fracture,  (3)  loss  of  reflexes,  (4)  priapism, 
6 


82  ^  MINOR  AND  EMERGENCY  SURGERY 

and  in  serious  cases  (5)  hyperpyrexia.  The  local 
manifestations  of  fracture  consist  of:  (i)  displace- 
ment, (2)  deformity,  (3)  paralysis  of  the  nerves 
emerging  near  to  and  below  the  site  of  compression, 
(4)  altered  mobility,  (5)  pain,  (6)  tenderness,  and 
usually  (7)  crepitus.  The  prognosis  is  unfavorable, 
except  in  those  instances  in  which  the  cord  is  un- 
injured. Fractures  above  the  fourth  cervical  verte- 
bra are  nearly  always  fatal.  In  general,  the  per- 
centage of  mortality  decreases  as  the  fracture  is  to- 
ward the  lower  part  of  the  spine.  Every  precaution 
should  be  taken  against  the  development  of  pneu- 
monia, cystitis  and  pyelitis. 

These  patients  must  be  handled  and  transported 
with  the  greatest  care  and  gentleness,  lest  the  cord  be 
further  injured.  In  simple  fracture  of  the  cervical 
region  the  patient  should  be  put  to  bed  with  traction 
on  the  head,  but  if  the  cord  is  involved,  operative 
measures  must  be  resorted  to  within  twenty-four 
hours.  All  cases  of  fracture  of  the  spine  should  be 
placed  on  an  air  or  water  bed  and  surrounded  with 
sand  bags,  and  rigid  cleanliness  must  be  maintained 
to  avoid  the  formation  of  bed-sores.  Reduction 
may  be  wholly  or  partially  accomplished  by  (i)  anes- 
thesia, extension,  and  gradual  pressure,  ending  the 
operation  with  the  application  of  a  plaster-of -Paris 
jacket  or  a  brace,  or  (2)  by  open  operation,  exposing 
the  injured  area  to  view.  The  latter  is  preferable, 
since  it  permits  of  the  local  effects  of  the  manipula- 
tions being  observed.  The  selection  of  either  of 
these  methods  will  depend  upon  the  existing  circum- 
stances in  the  individual  case. 


SIMPLE  FRACTURES  83 

FRACTURES  OF  THE  CLAVICLE. 

Fractures  of  the  clavicle  are  extremely  common. 
In  addition  to  the  classic  symptoms  of  fracture,  the 
attitude  assumed  by  the  patient  is  always  significant 
of  this  injury,  since  the  action  of  the  sternocleido- 
mastoid muscle  elevates  the  inner  fragment  and  in- 
clines the  head  toward  the  injured  side.  Green- 
stick  fractures  occur  especially  in  children. 

In  cases  where  the  absence  of  deformity  is  particu- 
larly desirable,  the  patient  should  be  placed  upon  a 
firm  mattress  with  a  sand  bag  on  the  shoulder  and 
the  arm  bandaged  to  the  side.  This  position  must 
be  maintained  until  union  is  firm.  If  a  sharp  end 
of  one  fragment  projects,  the  skin  can  be  cocainized, 
incised  and  the  tip  removed  with  bone  forceps.  In 
the  majority  of  instances,  however,  the  surgeon  will 
be  compelled  to  select  a  method  of  ambulatory  treat- 
ment, because  the  cosmetic  result  is  usually  of  minor 
importance  and  the  patient  will  not  submit  to  con- 
finement to  bed.  Both  the  Sayre  dressing  and  the 
Velpeau  bandage,  or  a  modification  of  it,  are  ex- 
cellent dressings  for  these  cases.  The  arm  must  be 
fixed  to  the  side  with  the  forearm  flexed,  so  that  the 
finger  tips  will  rest  on  the  opposite  shoulder.  Pads 
of  lint  or  cotton  are  placed  in  the  axilla,  between  the 
elbow  and  chest  and  under  the  palm  of  the  hand  to 
avoid  excoriation  of  the  skin  surfaces.  The  applica- 
tion of  either  of  these  dressings  may  be  preceded  by 
fixing  a  firm  compress  at  the  site  of  fracture  with  ad- 
hesive plaster. 

To  apply  the  Sayre  dressing: 


84'  MINOR  AND  EMERGENCY  SURGERY 

1.  Fix  the  arm  in  the  proper  position. 

2.  Cut  two  strips  of  adhesive  plaster  3  1/2  inches 
wide  and  about  2  yards  long. 

3  Wrap  one  strip  once  around  the  middle  of  the 
arm  at  an  exact  right  angle  to  its  longitudinal  axis 
and  pin  or  stitch  it  to  itself,  being  careful  not  to  im- 
pede the  circulation. 

4.  Bring  this  strip  across  the  back  and  completely 
around  the  chest. 

5.  Commence  the  second  strip  on  the  shoulder  of 
the  sound  side. 

6.  Carry  this  strip  diagonally  across  the  back, 
imder  the  elbow  on  the  injured  side  (cutting  a  slit 
for  the  olecranon  process) ,  and  across  the  chest  to  the 
starting-point. 

To  apply  a  modified  Velpeau  bandage . 

1.  Fix  the  arm  in  the  proper  position. 

2.  Begin  a  2  1/2  inch  wide  muslin  bandage  on  the 
shoulder  of  the  affected  side,  bring  down  the  front  of 
the  arm,  under  the  elbow,  up  the  back  of  the  arm, 
across  the  starting-point  on  the  shoulder,  diagonally 
across  the  front  of  the  chest,  under  the  opposite 
axilla,  around  the  back,  across  the  front  of  the  flexed 
elbow,  around  the  other  side  of  the  chest  again  and 
back  to  the  starting-point.  These  turns  should  be 
repeated  six  times,  each  one  just  overlapping  the 
previous  one,  and  the  dressing  completed  by  circular 
turns  around  the  chest  from  below  upwards  until  the 
entire  arm  and  forearm  are  concealed  by  the  bandage. 

This  dressing  should  be  removed  and  re-applied 
every  five  or  six  days  and  the  skin  wiped  with  alcohol. 
Union  is  generally  firm  at  the  end  of  five  weeks. 


SIMPLE  FRACTURES  85 

FRACTURES  OF  THE  HUMERUS. 

Classification : 


Upper  epiphysis 


Shaft 


Lower  epiphysis 


Anatomical  neck. 

Surgical  neck. 

Separation  of  the  epiphysis. 

Through  the  lesser  tuberosity. 

Through  the  great  tuberosity. 

Transverse  supracondyloid. 
Separation  of  the  epiphysis. 
Internal  epicondyle. 
Internal  condyle. 
External  condyle. 
T-fracture. 


Fracture  of  the  anatomical  neck  is  usually  impacted ; 
fracture  through  the  greater  tuberosity  may  be 
impacted.  In  the  former  the  impaction  should  never 
be  interfered  with,  but  in  the  latter  breaking  up  of 
the  impaction  is  essential.  All  fractures  of  the  upper 
end  of  the  humerus  should  be  radiographed,  and  ex- 
amined and  reduced  under  anesthesia.  Swelling  may 
be  avoided  by  bandaging  from  the  fingers  to  the 
point  of  fracture.  A  satisfactory  dressing  for  these 
cases  consists  of  a  A-shaped  pad,  extending  the  en- 
tire length  of  the  arm  with  the  apex  in  the  axilla. 
Position  may  be  maintained  by  a  strip  of  adhesive 
plaster  carried  over  the  opposite  shoulder  and  re- 
enforced  by  shoulder  cap  of  plaster  of  Paris  (Fig.  12). 
The  shoulder  cap  is  easily  prepared  by  making  a 
fiat  piece  of  several  turns  of  plaster-of-Paris  ban- 
dages and  then  moulding  to  the  shoulder  and  arm. 
A  firm  bandage  enclosing  the  injured  arm  and  chest 
affords  additional  support.     The  patient  being  in  a 


86 


MINOR  AND  EMERGENCY  SURGERY 


constantly  erect  or  semi-recumbent  position,  the 
wrist  should  be  suspended  in  a  sling,  so  that  the 
weight  of  the  arm  will  pull  against  the  fracture. 
If  a  new  shoulder  cap  is  made  at  the  end  of  the 
first  week  it  will  fit  more  snugly  than  the  first  one, 
because  of  the  subsidence  of  swelling.  When  the 
head  of  the  bone  become  necrotic,  complete  re- 
moval of  the  diseased  bone  is  more  prudent  than 
temporizing  with  palliative  measures. 


Fig.  12. — a,  A-shaped  splint  in  axilla;   b,  shoulder  cap  applied  and  arm 
in  proper  position  for  bandaging. 


Injury  of  the  nerves  of  the  arm  is  often  concomi- 
tant to  fractures  of  the  shaft  of  the  humerus.  The 
musculo-spiral  may  become  involved  in  the  callus 
formation,  evidenced  by  wrist-drop.  Careful  ex- 
amination, accurate  diagnosis,  exact  approximation 
of  the  fragments  and  rigid  immobilization  are  of  the 
utmost  importance  in  these  cases.     After  reduction, 


SIMPLE  FRACTURES  87 

the  following  method  of  treatment  of  fractures  of  the 
shaft  gives  exceedingly  satisfactory  results : 

Apply  coaptation  splints  by  wrapping  three  or 
four  narrow  strips  of  adhesive  plaster  around  five 
thin  strips  of  wood  extending  from  the  axilla  to  the 
elbow,  cotton  being  placed  underneath.  These  splints 
should  be  securely  fixed  with  a  bandage,  a  shoulder 
cap  applied,  the  arm  bandaged  to  the  side  and  the 
wrist  placed  in  a  sling.  This  dressing  should  be  re- 
applied every  week  or  so,  with  an  assistant  making 
continual  traction  at  each  renewal.  If  the  fragments 
tend  to  overlap,  better  results  will  be  obtained  by 
encasing  the  entire  arm  in  plaster-of -Paris  or  by  using 
constant  extension  by  means  of  weights,  in  a  manner 
similar  to  that  described  on  p.  68. 

Fractures  of  the  lower  end  of  the  humerus  usually 
extend  into  the  elbow-joint  and  the  necessity  for  an 
exact  understanding  of  the  nature  of  the  injury  can- 
not be  too  strongly  emphasized.  Entire  functional 
recovery  is  always  doubtful,  because  complete  re- 
duction is  often  impossible  or  the  callus  formation 
may  interfere  with  proper  motion.  It  should  be  re- 
membered that  with  the  forearm  extended  the  olec- 
ranon process  of  the  ulna  and  the  two  condyles  of 
the  himienis  normally  lie  in  a  straight  line.  Swell- 
ing rapidly  occurs  in  all  these  cases  and  must  be 
disregarded,  as  immediate  reduction  is  imperative. 
Much  of  the  extravasation,  however,  may  be  quickly 
eliminated  by  bandaging  for  a  few  minutes  from  the 
fingers  to  the  arm  with  an  elastic  bandage.  Sepa- 
ration of  the  epiphysis  and  supracondyloid  fractures 
are  the  only  two  types  of  fracture  of  the  lower  end 


88   -         MINOR  AND  EMERGENCY  SURGERY 

of  the  humerus  that  require  fixation  of  the  forearm 
at  a  right  angle.  This  position  is  best  secured  by 
placing  an  anterior  angular  splint  upon  the  arm  and 
forearm  over  a  roller  bandage.  Condyloid  fractures 
may  be  treated  in  either  the  extended  or  acutely 
flexed  (Jones)  position.  Unless  great  care  is  exer- 
cised, "gun-stock"  deformity,  or  loss  of  the  carrying 


Fig.  13. 


-Adhesive  straps  applied  to  maintain  acute  flexion  of  the 
forearm  (Jones'  position). 


angle  not  infrequently  follows  these  fractures.  The 
extended  position  would  seem  to  maintain  reduction 
and  preserve  the  carrying  angle  better  than  acute 
flexion,  but  on  the  other  hand,  when  the  forearm  is 
flexed,  the  olecranon  process  and  the  tense  triceps 
tendon  both  splint  the  line  of  fracture  and  this  atti- 


SIMPLE  FRACTURES  89 

tude  will  be  much  more  useful  to  the  patient  should 
ankylosis  result.  Extensive  swelling  is  an  absolute 
contra-indication  to  the  flexed  position,  because  the 
pressure  therefrom  may  interfere  with  the  circulation. 
Acute  flexion,  then,  is  the  preferable  position  for 
condyloid  fractures,  unless  there  is  great  swelling,  or 
reduction  of  the  deformity  cannot  be  satisfactorily 
maintained.  Even  if  it  is  necessary  to  utilize  the 
extended  position,  the  dressings  may  be  removed 
after  a  week  or  two  and  the  forearm  flexed  under  an- 
esthesia. When  treating  by  extention,  an  iron  bar 
may  be  fitted  to  the  inside  of  the  sound  limb  and 
applied  reversed  on  the  inside  of  the  injured  limb, 
to  preserve  the  carrying  angle.  If  the  flexed  po- 
sition is  decided  upon,  the  proper  attitude  may  be 
easily  maintained  by  fixing  with  four  of  five  cir- 
cular strips  of  adhesive  plaster  including  both  the 
arm  and  forearm  (Fig.  13).  Motion  should  not  be 
permitted  for  at  least  a  month. 

FRACTURES  OF  THE  FOREARM 
Classification : 

Radius  and  Ulna         <  ,.  1         ,  .  ,  s 

(^  incomplete  (green-stick). 

Head  and  neck. 

Separation  of  the  epiphysis. 

Shaft. 

CoUes. 

Reversed  CoUes. 

Olecranon  process. 

Coronoid  process. 

Shaft. 

Styloid  process. 


Radius 


Ulna 


Precise  adjustment  of  the  fragments  is  essential 


90'^  MINOR  AND  EMERGENCY  SURGERY 

when  the  radius  and  ulna  are  both  fractured,  be- 
cause of  the  probability  of  a  synostosis  resulting 
from  the  agglutination  of  the  callus  from  each  bone. 
When  there  is  overlapping  with  shortening,  exten- 
sion must  be  continual  to  overcome  it.  The  position 
of  the  forearm  should  be  that  which  will  most 
widely  separate  the  two  bones  and  be  the  most 
comfortable  for  the  patient :  as  a  rule,  semi-pronation. 
The  exception  is  when  the  radius  is  fractured  above 
the  insertion  of  the  pronator  radii  teres;  then  the 
position  should  be  complete  supination.  The  pri- 
mary roller  bandage  must  be  omitted  and  the 
splints  wider  than  the  forearm  in  these  cases,  in 
order  to  avoid  lateral  pressure,  which  tends  to  force 
the  bones  together;  for  the  same  reason,  plaster-of- 
Paris  should  never  be  used.  An  anterior  and  poster- 
ior flat  wooden  splint  are  required  and  they  must  be 
accurately  padded  to  fit  the  irregular  surfaces  of 
the  forearm.  The  anterior  one  is  necessarily  the 
shorter  and  every  precaution  should  be  taken  that 
the  upper  limit  does  not  exert  pressure  upon  the 
brachial  artery  where  it  crosses  the  elbow-joint. 
Both  splints  extend  to  the  knuckles  and  the  sling  in 
which  the  forearm  is  carried  should  uniformly  sup- 
port the  entire  distance  from  the  elbow  to  that 
point. 

Fractures  of  the  head  and  neck  and  separation  of 
the  epiphysis  of  the  radius  are  not  common  and  are 
treated  in  acute  flexion.  If  the  functional  result 
is  unsatisfactory,  excision  of  the  head  of  the  bone 
may  be  considered. 

Fractures   of  the   shaft   of  the   radius   occurring 


SIMPLE  FRACTURES 


91 


above  the  insertion  of  the  pronator  radii  teres 
should  obviously  be  treated  in  a  supinated  position. 
If  below  this  point,  however,  semi-pronation  and  the 
plaster-of-Paris  splints  recommended  for  Colles' 
fractures  are  preferable. 

Colles'  fractures  are  transverse  fractures  of  the 
radius  about  an  inch  above  the  styloid  process. 
The  lower  fragment  is  tipped  upward  and  backward 
and  is  usually  impacted  or  comminuted.  In  a 
reversed  Colles'  (rare)  the  deformity  is  anterior. 
Radiography  is  often  the  only  diagnostic  method 
that  will  positively  differentiate  a  Colles'  fracture 
from  a  sprain  or  dislocation  of  the  wrist,  unless  the 
silver-fork  deformity  is  pronounced.  Permanent  de- 
formity and  impairment  of  function  will  surely 
follow  an  incompletely  reduced  Colles  fracture, 
hence  accurate  approximation  of  the  fragments  is 
of  paramount  importance.  Reduction  is  accom- 
plished by  fixing  the  forearm  with  one  hand  and 
gripping  the  hand  of  the  injured  arm  with  the 
other,  making  momentary  traction  with  overexten- 
sion steadily,  and  then  suddenly  flexing  the  hand. 
Having  secured  satisfactory  alignment,  these  frac- 
tures do  not  tend  to  recur.  The  results  obtained 
from  the  following  method  of  treatment  are  much 
better  than  those  derived  from  the  time-honored 
Bond,  or  pistol-shaped,  splint,  because  the  provi- 
sional callus  is  absorbed  more  rapidly,  stiffness  is 
absent,  and  the  function  of  the  wrist  joint  is  un- 
impaired. 

I.  With  the  forearm  supinated  and  the  hand  ad- 
ducted,  have  an  assistant  support  the  upper  end  of 


92 


MINOR  AND  EMERGENCY  SURGERY 


the  forearm  with  one  hand  and  grasp  the  fingers 
and  palm  with  the  other. 

2 .  Apply  a  primary  roller  gauze  bandage  from  the 
metacarpo-phalangeal  joints  to  the  elbow. 

3.  Mould  a  plaster-of -Paris  splint  to  the  anterior 
half  of  the  forearm  and  hand,  extending  to  the 
knuckles. 

4.  Mould  a  posterior  splint  in  the  same  manner 
(Fig.  14). 


Fig.   14. — ^Plaster-of-Paris  dressing  for  CoUes'  fracture,     a.  Anterior 
splint  applied;  b,  both  splints  applied. 

5.  When  hardened,  cut  the  primary  bandage 
between  the  splints  on  both  sides. 

6.  Apply  an  external  bandage. 

7.  On  the  second  day  remove  the  posterior  splint 
and  gently  massage  the  site  of  fracture  for  ten  min- 
utes, with  the  finger-tips  sHghtly  lubricated. 

8.  Replace  the  posterior  splint,  pronate  the 
arm,  remove  the  anterior  splint  and  massage  again. 

9.  Continue  these  procedures  every  two  or  three 


SIMPLE  FRACTURES 


93 


days  for  two  weeks  and  then  begin  passive  motion 
at  the  wrist  and  fingers. 

lo.  Remove  the  splints  permanently  at  the  end  of 
three  weeks. 

Reversed  Colles'  fractures  and  separations  of  the 
epiphysis  of  the  radius  may  be  similarly  treated 
after  reduction. 

Fractures  of  the  olecranon  process  of  the  ulna  are 
followed  by  the  best  results  when  operated  upon. 
If  otherwise  treated,  the  forearm  should  be  extended 
on  a  well  padded  splint,  a  small  pad  placed  above  the 
upper  fragment  and  firmly  secured  by  a  strip  of  ad- 
hesive plaster  applied  obliquely  and  the  whole  cov- 
ered with  a  muslin  bandage.  These  cases  usually 
terminate  in  fibrous  union  when  not  operated  upon 
but  the  functional  result  is  uniformly  satisfactory. 
Should  the  presence  of  synovial  fluid  between  the 
fragments  seriously  interfere  with  imion,  it  will  be 
necessary  to  freshen  the  surfaces  of  the  fragments 
and  suture  them  together. 

The  greater  number  of  fractures  of  the  coronoid 
process  of  the  ulna  are  found  with  simultaneous 
backward  dislocations.  The  existing  dislocation 
must  be  reduced  and  the  arm  put  up  in  acute  flexion. 

Fractures,  of  the  shaft  and  styloid  process  of  the 
ulna  should  be  dressed  in  the  same  manner  as  frac- 
tures of  the  shaft  of  the  radius, 

FRACTURES  OF  THE  METACARPAL  BONES. 

In  cases  where  there  is  but  little  shortening,  the 
fist   may  be   closed  upon  a  rolled-up  bandage  and 


94  MINOR  AND  EMERGENCY  SURGERY 

covered  with  another  bandage.     When  the  short- 
ening is  pronounced,  extension  is  preferable : 

1.  With  the  forearm  and  hand  pronated,  place  a 
gauze  pad  under  the  palm  of  the  hand. 

2.  Apply  two  lateral  strips  of  adhesive  plaster  to 
the  finger  corresponding  to  the  fractured  bone. 

3.  Place  a  well  padded  straight  splint  under  the 
forearm  and  hand. 

4.  Make  traction  on  the  adhesive  strips  and  fix 
them  to  the  under  surface  of  the  splint. 

5.  Place  a  piece  of  rubber  tubing  on  each  side  of 
the  fracture  and  secure  with  adhesive  plaster. 

6.  Bandage  from  the  tips  of  the  fingers  to  the 
elbow. 

FRACTURES  OF  THE  PELVIS. 

The  gravity  and  treatment  of  these  injuries  depend 
upon  the  degree  of  shock,  the  integrity  of  the  pel- 
vic girdle,  and  the  extent  of  injury  of  the  pelvic  vis- 
cera. The  most  important  complications  are:  (i) 
rupture  of  the  bladder,  (2)  rupture  of  the  deep  urethra, 
(3)  laceration  of  the  vagina  and  rectum,  and  (4)  in- 
ternal hemon'hage.  To  determine  whether  or  not 
the  bladder  has  been  ruptured,  do  a  sterile  surgical 
catheterization,  empty  the  bladder  of  its  contents  as 
far  as  possible,  inject  a  known  quantity  of  a  sterile 
liquid  and  measure  the  amount  withdrawn.  A  ma- 
terial difference  between  the  amount  injected  and 
the  amount  withdrawn  indicates  rupture.  The 
withdrawal  of  clear  urine  when  catheterizing  is  cor- 
roborative evidence  that  the  bladder  is  uninjured, 
whereas  the  absence  of  urine  or  hematuria  is  stigges- 


SIMPLE  FRACTURES  95 

tive  of  rupture.  If  the  rupture  is  intraperitoneal, 
the  S3n2iptoms  are  profound  shock,  increasing  rapidity 
of  the  pulse  and  abdominal  tenderness.  If  extraperit- 
oneal (usually  into  the  space  of  Retzius),  there  is 
slight  shock,  pain,  partial  retention  of  urine  and  sec- 
ondary sepsis.  Prompt  diagnosis  is  important  and 
immediate  laparotomy  or  perineal  section  impera- 
tive. Rupture  of  the  deep  urethra  is  evidenced  by 
dysuria,  strangury,  swelling  and  ecchymosis  in  the 
perineum  and  scrotum  due  to  the  extravasation  of 
blood  and  urine,  and  if  rupture  is  complete,  by  reten- 
tion of  urine.  In  all  these  cases  of  fracture  the  pelvis 
should  be  surrounded  with  broad  strips  of  adhesive 
plaster  and  the  patient  put  to  bed  with  sand  bags 
on  each  side,  or  slung  in  a  hammock.  A  pillow  must 
be  placed  under  the  knees  so  that  the  flexion  will  re- 
lax the  abdominal  muscles  as  well  as  those  of  the 
thigh.  Injured  soft  structures  should,  of  course,  be 
repaired  and  appropriately  treated. 

FRACTURES  OF  THE  FEMUR. 

Classification : 

Head  (very  rare) 

^1  /     Intracapsular. 

I     Extracapsular. 

f     Upper  of  femur. 

^  , .  ...  Great  trochanter, 

beparation  01  epiphyses       <     ,.  ^       1       . 

I     Lesser  trochanter. 

I     Lower  of  femur. 

f    Upper  third. 

Shaft  I     Middle  third. 

[     Lower  third. 

ISupracondyloid. 
External  condyle. 
Internal  condyle. 


96'  MINOR  AND  EMERGENCY  SURGERY 

Intracapsular  fractures  of  the  neck  of  the  femur 
are  common  in  the  aged,  occurring  as  the  result  of 
trivial  traumatism,  and  are  usually  not  impacted. 
Extracapsular  fractures  are  found  more  frequently 
in  young  adults,  due  to  direct  violence  and  impacted 
as  a  rule.  There  is  shoitening,  eversion,  defoimity, 
pain,  loss  of  function,  mobility  and  crepitus  (ex- 
cept when  there  is  impaction).  It  is  of  far  greater 
importance  to  distinguish  an  impacted  from  a  non- 
impacted  fracture  of  the  neck  of  the  femur  than  it 
is  to  differentiate  intracapsular  and  extracapsular 
types.  These  cases  should  never  be  examined  for 
crepitus  under  anesthesia  as  the  periosteum  may 
be  torn  or  an  impaction  broken  up,  nor  should  the 
impaction  ever  be  interfered  with,  unless  the  patient 
is  a  young  healthy  adult  and  the  deformity  ex- 
ceptionally pronounced.  Gradual  increase  of  short- 
ening during  the  first  day  or  two  indicates  liberation 
of  an  impaction.  The  prognosis  is  grave  in  old 
people,  because  death  often  ensues  from  exhaustion 
or  hypostatic  pneumonia,  consequent  to  the  con- 
finement to  bed.  Fibrous  union  frequently  results 
from  intracapsular  fractures  but  there  is  always 
bony  union  in  extracapsular  fractures.  Stiffness 
invariably  follows  in  these  cases  because  of  the  large 
amount  of  provisional  callus  present.  In  the  aged, 
regard  for  the  constitutional  condition  should  super- 
sede consideration  of  the  injury.  The  patient 
should  be  treated  on  a  fracture  bed,  his  back  sup- 
ported by  a  back-rest  and  the  limb  steadied  with 
sand  bags  on  both  sides.  Scrupulous  personal 
cleanliness  and  good  nursing  are  essential  to  avoid 


SIMPLE  FRACTURES  97 

the  formation  of  bed-sores.  In  younger  adults 
the  best  results  are  obtained  from  the  use  of  exten- 
sion, re-enforced  with  a  well  padded  side  splint  ex- 
tending from  the  axilla  to  the  foot.  This  relieves 
the  pain,  gives  the  patient  comparative  comfort 
and  corrects  the  eversion. 

The  treatment  of  separation  of  the  epiphyses  of 
the  fem.ur,  great  trochanter  and  lesser  trochanter 
consists  of  reduction  of  the  deformity  by  manipu- 
lation and  fixation  of  the  part  with  splints  or  a 
plaster-of -Paris  dressing. 

Fractures  of  the  shaft  of  the  femur  usually  present 
extreme  deformity,  because  the  line  of  fracture  is 
nearly  always  oblique  and  the  displacement  is  ex- 
aggerated by  the  powerful  muscular  action.  Two 
or  three  inches  of  shortening  is  to  be  expected.  The 
angular  displacement  is  upward  in  the  upper  third, 
outward  in  the  middle  third,  and  backward  in  the 
lower  third.  These  fractures  are  never  impacted 
and  inability  to  elicit  crepitus  indicates  the  presence 
of  soft  structures  between  the  fragments.  The 
emergency  treatment  is  important,  as  these  cases 
should  not  be  transported  imtil  the  fracture  is  firmly 
immobilized.  The  best  emergency  dressing  consists 
of  coaptation  splints,  supported  by  a  long  axillary 
splint  on  the  outside  and  another  on  the  inside 
reaching  from  the  groin  to  the  foot.  These  cases 
should  all  be  treated  on  a  fracture  bed  by  Buck's 
extension,  re-enforced  by  the  foregoing  lateral 
splints.  The  foot  must  always  be  fixed  at  a  right 
angle  and  a  pad  of  cotton  placed  imder  the  tendo 
Achilles,  to  prevent  pressure  upon  the  heel.  Frac- 
7 


gS  MINOR  AND  EMERGENCY  SURGERY 

tures  of  the  middle  third  are  treated  by  extension 
in  a  straight  line.  For  fractures  of  the  upper  and 
lower  thirds  it  is  better  to  use  a  double  inclined  plane, 
with  the  extension  applied  above  the  knee  only, 
to  induce  relaxation  of  the  muscles  responsible  for 
the  deformity.  A  plaster-of-Paris  dressing  includ- 
ing the  entire  leg  and  pelvis  has 'also  been  recom- 
mended and  widely  employed  for  fractures  of  the 
shaft  of  the  femur.  Notwithstanding  the  fact  that 
by  virtue  of  its  solidity  this  dressing  presumes  to 
give  perfect  immobilization,  its  weight  and  unclean- 
liness  are  the  source  of  such  great  discomfort  to 
the  patient  that  it  has  been  unfavorably  regarded 
and  discarded  by  many.  In  addition  to  these 
objectionable  features,  in  the  author's  experience 
the  results  derived  from  this  method  of  treatment 
have  not  been  uniformly  satisfactory,  as  they  have 
been  when  extension  was  employed.  Fractures  of 
the  femur  in  infants  and  young  children  are  usually 
green-stick  or  transverse  fractures  and  constant 
traction  is  not  as  essential  as  in  adults.  Moulded 
splints  of  pasteboard  or  binder's  board  may  be 
applied  and  secured  by  a  bandage,  or  both  legs  may 
be  encased  in  plaster-of-Paris  bandages  and  sus- 
pended vertically  by  the  feet  from  a  crossbar  over 
the  bed.  Great  care  should  be  taken  to  avoid 
pressure  necrosis  of  the  foot. 

FRACTURES  OF  THE  PATELLA. 

When  due  to  direct  violence,  these  fractures  are 
often  comminuted  and  there  is  very  little  separa- 
tion of  the  fragments  because  the  integrity  of  the 


SIMPLE  FRACTURES  99 

capsule  is  preserved.  Contrariwise,  if  caused  by- 
indirect  violence  (muscular  action),  the  capsule,  as 
well  as  the  patella  itself,  is  broken ;  the  line  of  fracture 
is  transverse,  displacement  is  pronounced  and  over- 
lying soft  tissues  frequently  drop  between  the 
fragments.  Consequently,  bony  union  is  excep- 
tional, unless  operative  measures  are  resorted  to. 
Profuse  swelling  occurs  immediately  and  may  be 
reduced  by  immobilization  and  ice,  with  the  leg  in 
the  extended  position.  A  relatively  large  propor- 
tion of  these  cases  require  operative  interference  for 
the  correction  of  the  existing  pathological  conditions 
and  the  selection  of  a  conservative  or  radical  method 
of  treatment  will  necessarily  depend  upon  (i)  the 
amount  of  separation  of  the  fragments,  (2)  the 
integrity  of  the  capsule,  (3)  the  interposition  of 
soft  structures  and  (4)  the  surgeon's  discretion  in 
each  individual  case.  Exposure  of  the  knee-joint, 
and  particularly  of  its  synovial  membrane,  is  an 
operation  of  considerable  gravity  which  may  even 
jeopardize  the  patient's  life  if  performed  under 
difficulties,  owing  to  the  rapidity  with  which  in- 
fection is  absorbed.  Conversely,  given  perfect 
asepsis  and  technic  followed  by  primary  union, 
the  anatomical  and  functional  results  are  much 
better  than  when  the  case  is  treated  conservatively. 
To  generalize,  it  may  be  said  that  when  crepitus 
can  be  elicted  and  it  is  possible  to  approximate  the 
fragments  within  1/4  of  an  inch,  a  reasonably 
satisfactory  result  may  be  expected  from  the  use 
of  immobilization  and  splints  alone.  If  crepitation 
cannot  be  obtained  or  it  is  impossible  to  approxi- 


lOo  MINOR  AND  EMERGENCY  SURGERY 

mate  the  fragments,  incision  and  suturing  are  both 
justifiable  and  essential.  F.  D.  Gray  says,  "A  badly 
functionating  leg  from  fracture  of  the  patella,  with- 
out operation,  is  near  malpractice,  while  a  stiff  knee 
as  a  result  of  operative  procedure  is  in  the  same 
category." 

If  operation  is  deemed  unnecessary  or  inadvis- 
able, the  limb  must  be  placed  upon  a  posterior 
padded  straight  splint  extending  from  the  upper 
third  of  the  thigh  to  the  lower  third  of  the  leg, 
with  a  gauze  pad  under  the  knee-joint.  A  small 
compress  is  then  applied  above  the  upper  fragment 


Fig.  15. — Method  of  treating  fracture  of  the  patella. 

and  secured  by  means  of  an  oblique  strip  of  adhesive 
plaster;  another  compress  is  fixed  below  the  lower 
fragment  in  the  same  manner,  so  that  the  plaster 
strips  cross  on  each  side  of  the  knee-joint  (Fig.  15). 
A  convenient  means  of  fastening  the  plaster  strips 
is  to  drive  two  nails  or  pegs  into  the  posterior 
splint  on  each  side.  The  limb  must  be  bandaged 
from  the  toes  to  the  upper  limit  of  the  splint.  If 
union  appears  firm  at  the  end  of  six  or  seven  weeks, 
passive  motion  and  massage  may  be  cautiously 
be;run. 


SIMPLE  FRACTURES  loi 

Should  •  open  operation  be  selected,  every  detail 
of  preparation  and  technic  must  be  accorded  ade- 
quate attention  in  order  that  all  may  contribute  to 
ultimate  success  and  a  perfect  recovery.  There  is 
still  some  diversity  of  opinion  as  to  the  preferable 
mode  of  procedure,  but  the  concensus  of  opinion  seems 
to  be  that,  as  a  rule,  clearing  out  the  space  between 
the  fragments  and  suturing  the  capsule  and  overly- 
ing tissues  with  iodine  catgut,  under  local  or  general 
anesthesia,  are  all  that  are  necessary  to  effect  a  cure, 
although  some  surgeons  consider  wiring  of  the  bone 
fragments  essential.  Tincture  of  iodine  may  be 
dropped  along  the  skin  wound,  the  knee  wrapped 
in  gauze  saturated  with  aluminum  acetate  solution 
and  the  limb  bandaged  to  the  posterior  splint. 
These  items  minimize  the  danger  of  infection,  restore 
the  injured  structures  to  their  normal  anatomical 
relationship,  obviate  the  introduction  of  non-absorb- 
able  suture  material  and  rapidly  bring  about  firm 
union.  Silver  wire  sutures  act  as  foreign  bodies  and 
necrosis  of  bone  frequently  follows  their  use.  The 
patella  is  refractured  more  often  than  any  other 
bone  in  the  body,  and  the  patient  should  be  warned 
accordingly.  Corner,  of  London,  maintains  that 
most  refractures  in  cases  treated  by  operative  meas- 
ures occur  in  the  first  year  after  the  original  injury, 
while  those  cases  treated  otherwise  occur  more  fre- 
quently after  the  first  year 


I02 


MINOR  AND  EMERGENCY  SURGERY 


FRACTURES  OF  THE  LEG. 


Classification : 

Tibia  and  fibula 

Upper  epiphysis. 


Tibia 


Fibula 


Upper  end 
Shaft. 
Lower  end 


Oblique. 

Transverse. 

Region  of  the  ankle 
Internal  maleolus. 


Lower  epiphysis. 

Upper  epiphysis. 
Upper  end. 
Shaft. 

'  Pott's. 
External  maleolus. 


Lower  end 


Lower  epiphysis. 


Fractures  of  both  the  tibia  and  fibula  are  common, 
often  compound  and  easily  diagnosed.  When  due 
to  direct  violence,  the  line  of  fracture  is  usually  trans- 
verse, both  bones  being  broken  at  the  same  level, 
while  if  produced  by  indirect  violence,  the  fractures 
are  usually  oblique  and  seldom  occur  at  the  same 
level.  Those  due  to  direct  force  nearly  always  be- 
come compound  within  the  first  week,  because  of  the 
deficient  vascularity  of  the  overlying  tissues.  The 
anatomical  location  of  the  bones  is  so  superficial  that 
the  skin  and  subcutaneous  fascia  are  unable  to  with- 
stand the  damage  inflicted  by  the  traumatism  and 
sloughing  with  exposure  of  bone  results.  The  deform- 
ity in  these  cases,  however,  is  slight  and  easily  over- 


SIMPLE  FRACTURES  103 

come  and  does  not  tend  to  recur  after  reduction. 
On  the  contrary,  in  fractures  due  to  indirect  violence 
the  deformity  is  pronounced  and  may  resist  all 
efforts  at  reduction.  If  the  displacement  is  easily  re- 
duced, the  primary  swelling  insignificant  and  no  ex- 
tensive contusion  apparent,  a  plaster-of-Paris  dress- 
ing encasing  the  foot,  ankle,  leg  and  knee  is  the  most 
efficient  method  of  treatment,  provided  the  surgeon 
is  constantly  on  the  alert  for  evidence  of  pressure  and 
skin  necrosis.  If  the  cast  is  too  tight,  it  will  inter- 
fere with  the  circulation,  while  if  it  is  too  loose,  it 
will  permit  motion  and  perhaps  displacement  at  the 
point  of  fracture.  The  dressing  is  best  applied  over 
a  thin  layer  of  wool  and  should  be  removed  within 
six  or  seven  days,  unless  indicated  earlier  by  pain  or 
swelling  of  the  toes.  This  affords  an  opportimity  to 
examine  the  site  of  injury  and  to  apply  a  second  cast 
which  invariably  fits  better  than  the  original  one. 
When  there  is  considerable  extravasation  or  super- 
ficial contusion,  a  wet  dressing  and  padded  lateral 
splints  should  be  applied  and  the  leg  placed  in  a  frac- 
ture box  with  a  wool  pad  beneath  the  tendo  Achilles, 
to  avoid  pressure  on  the  heel.  After  the  swelling 
has  subsided  and  the  skin  has  healed,  the  plaster-of- 
Paris  may  be  applied  as  before.  If  the  lines  of  fracture 
are  very  oblique  and  the  overlapping  is  persistent,  it 
will  be  necessary  to  employ  the  extension  apparatus 
or,  as  a  last  resort,  perform  a  subcutaneous  tenotomy 
on  the  tendo  Achilles,  to  relieve  the  tension.  The 
foot  should  be  immobilized  at  a  right  angle  in  all 
these  cases. 

The  treatment  of  separation  of  the  epiphyses  of 


I04'         MINOR  AND  EMERGENCY  SURGERY 

the  tibia  consists  of  reduction  of  the  displacement 
and  fixation  in  plaster-of -Paris. 

In  all  fractures  of  the  tibia  alone  the  fibula  per- 
forms the  function  of  a  splint  for  the  broken  bone  so 
that  the  deformity  and  displacement  are  not  marked. 
The  treatment  is  practically  identical  with  that  em- 
ployed for  simultaneous  fracture  of  both  bones,  ex- 
cept those  of  the  lower  end  involving  the  ankle-joint, 
which  cases  demand  early  passive  motion  and  mas- 
sage to  prevent  subsequent  ankylosis. 

The  treatment  of  separation  of  the  epiphyses  of  the 
fibula  consists  of  fixation  by  splints  or  a  plaster-of- 
Paris  bandage. 

Fractures  of  the  upper  end  and  shaft  of  the  fibula 
are  best  placed  in  a  fracture  box  for  a  week  and  later 
encased  in  plaster-of-Paris. 

Fracture  of  the  lower  end  of  the  fibula,  or  Pott's 
fracture,  is  a  complicated  fracture.  It  usually  occurs 
about  3  inches  above  the  malleolus,  rupturing  the 
internal  lateral  ligament,  and  wrenching  off  a  spicule 
of  bone  from  the  tibia.  There  is  always  a  loss  of  con- 
tinuity between  the  foot  and  malleolus,  while  if  the 
anterior  tibio-fibular  ligament  has  been  ruptured  and 
the  mortise  considerably  disturbed,  the  ankle-joint  is 
widened  and  the  astragalus  displaced  upward  and 
backward.  The  foot  is  invariably  everted  in  all 
cases  of  Pott's  fracture.  The  accurate  correction  of 
the  deformity  depends  upon  the  re-establishment  of 
normal  anatomical  relationship,  so  that  an  exact  con- 
ception of  the  pathological  picture  is  of  the  utmost 
importance.  Reduction  is  best  accomplished  by 
firmly  grasping  the  toes  and  heel,  exerting  direct  down- 


SIMPLE  FRACTURES 


105 


ward  traction  for  a  minute  or  two  and  swinging  the 
foot  into  position.  When  there  is  posterior  displace- 
ment, the  foot  must  also  be  pulled  forward.  If  the 
reduction  is  correct  and  complete  and  proper  posi- 
tion maintained,  the  pain  promptly  disappears. 
Inversion  of  the  foot  must  be  slightly  exaggerated 
throughout  the  treatment  of  these  fractures.  The 
most  satisfactory  appliance  is  the  Dupuytren  splint, 
which  is  an  internal  board  splint  extending  from  the 
knee  to  below  the  foot  and  padded  4  inches  thick 
to  just  above  the  malleolus.  The  foot  is  now  inverted 
by  pulling  the  toes  over  with  a  bandage.  In  spite 
of  its  efficiency,  this  dressing  is  often  so  uncomfort- 
able to  the  patient  that  plaster-of -Paris  dressings  are 
frequently  employed.  Whenever  the  annular  liga- 
ment is  torn  and  the  tibialis  posticus  is  released  from 
its  groove,  it  is  good  surgery  to  make  an  incision,  re- 
store the  tendon  of  the  tibialis  posticus  to  its  normal 
position  arid  suture  the  annular  ligament. 

Fractures  of  the  bones  of  the  foot  are  usually  accom- 
panied by  profuse  swelling  and  are  treated  with  the 
foot  extended  upon  the  leg  at  a  right  angle,  being 
supported  by  a  well  padded  splint  of  binder's  board 
until  the  swelling  subsides.  Plaster-of-Paris  may 
then  be  applied,  with  a  fiat-foot  plate  on  the  sole  of 
the  foot. 


CHAPTER  V. 

COMPOUND  FRACTURES  AND  TRAUMATIC 
AMPUTATIONS. 

Any  fracture  communicating  with  the  exterior 
is  termed  a  compound  fracture.  Single,  uncom- 
phcated  compound  fractures,  produced  from  within 
outward  and  with  the  tip  of  a  fragment  only  pro- 
jecting, need  not  be  considered  exceptionally  im- 
portant, as  the  rent  in  the  skin  usually  heals  kindly, 
converting  the  fracture  into  a  simple  one.  On  the 
contrary,  compound  comminuted  fractures  with 
extensive  destruction  of,  or  contusion  to,  the  ad- 
jacent soft  parts,  compound  fracture  dislocations, 
and  gun-shot  fractures  are  grave  injuries.  The 
more  severe  types  of  compound  fractures,  in  which 
amputation  is  partially  completed  by  the  inflicting 
traumatism  with  destruction  of  the  principal  blood 
supply,  may  be  viewed  as  traumatic  amputations. 
In  these  cases  the  cosmetic  and  functional  results 
as  well  as  the  life  of  the  patient  will  depend  upon : 

The   surgeon's  judgment   and  skill  in  each  case. 

The  wishes  of  the  patient  and  his  relatives  regard- 
ing the  proposed  and  advised  surgical  procedures. 

The  patient's  health,  constitution,  age  and  habits. 

The  integrity  of  the  circumference  of  the  limb. 

The  preservation  of  an  adequate  blood  supply 
to  the  injured  area  and  the  distal  parts. 

Proper  emergency  treatment. 
io6 


COMPOUND  FRACTURES  107 

Perfect  operative  technic. 

The  degree  to  which  it  is  possible  to  restore  the 
injured  structures  to  their  normal  relationship. 

Intelligent  after-treatment. 

Good  nursing. 

Besides  the  local  conditions,  six  possible  inter- 
current occurrences  must  be  considered:  shock, 
tetanus,  gangrene,  sloughing,  secondary  hemorrhage 
and  sepsis. 

Emergency  treatment  of  compound  fractures  and 
traumatic  amputations  is  essentially  that  of  the 
simple  fracture  plus  an  extensively  lacerated  wound. 
Hemorrhage  from  the  larger  blood-vessels  must  be 
immediately  controlled,  usually  requiring  either 
the  tourniquet  or  hemostatic  forceps.  Applying 
the  tourniquet  too  far  above  the  upper  limit  of  the 
injury  may  seriously  embarrass  subsequent  manage- 
ment of  the  case,  hence  the  site  of  constriction 
should  be  carefully  selected.  Large  foreign  bodies 
may  be  removed,  provided  that  it  can  be  done 
expeditiously,  but  no  bone  fragments  should  be 
disturbed.  The  injured  part  may  be  returned  to 
its  approximate  normal  position,  covered  with  a 
heavy  wet  dressing  and  bandaged  between  long 
splints.  The  patient  should  receive  a  hypodermic 
injection  of  morphine  and  be  transported  com- 
fortably to  the  hospital.  Even  in  event  of  a  trau- 
matic amputation  these  measures  are  permissible 
and  indicated.  It  is  best  to  do  nothing  further 
for  the  moment  since  the  injury  frequently  presents 
a  different  aspect  when  examined  in  the  hospital. 
Don't  perform,  amputations  on  the  street.     An  ampu- 


io8 


MINOR  AND  EMERGENCY  SURGERY 


tation  is  an  operation  of  no  small  magnitude,  cer- 
tainly not  one  to  be  done  on  a  street  corner. 
There  are  instances,  however,  in  which  it  may  be 
necessary  to  complete  a  traumatic  amputation  to 
release  the  patient  from  an  enormous  weight.  When 
this  is  done,  the  severed  member  should  also  be 
transferred  to  the  hospital,  because  many  patients 
will  desire  to  have  it  cared  for  by  an  undertaker. 

Operative  Treatment  of  Compound  Fractures  and 
Traumatic  Amputations. — Having  removed  the  pa- 
tient to  a  hospital  or  other  convenient  surroimdings, 
the  question  presents  in  severe  cases:  shall  the 
limb  be  immediately  amputated  or  shall  an  effort 
be  made  to  preserve  it,  notwithstanding  the  fact 
that  the  patient's  life  may  be  jeopardized?  The 
former  (primary  amputation)  may  be  designated 
radical  treatment,  while  the  latter  is  obviously  con- 
servative. The  answer  to  this  question  will  rest 
entirely  upon  the  surgeon's  judgment  after  care- 
ful consideration  of  all  the  facts  presenting  in  the 
individual  case,  provided  consent  of  the  patient 
and  his  relatives  to  the  procedures  selected  can  be 
obtained.  Factors  arguing  in  favor  of  one  or  the 
other  methods  of  dealing  with  a  compound  fracture 
or  a  traumatic  amputation  may  be  tabulated  con- 
veniently : 


Radical. 
Constitution  poor. 
Age  over  fifty. 
Alcoholic  habits. 
More   than   two-thirds   of   the 

circumference    of    the    limb 

destroyed. 


Conservative  . 
Constitution  good. 
Age  under  fifty. 
Temperate  habits. 
One-third  of    the  circumfer- 
ence of  the  limb  intact. 


COMPOUND  FRACTURES 


109 


Main  blood  supply  to  the  site 
of  injury  and  the  distal 
parts  destroyed. 

Surroundings  favoring  infec- 
tion. 

Proper  after-treatment  ques- 
tionable. 

Good  nursing  not  obtainable. 

If  a  clean  amputation  is  per- 
formed, the  patient's  life 
will  not  be  jeopardized. 


Adequate  blood  supply  to 
tlie  site  of  injury  and 
parts  beyond. 

Perfect  asepsis  and  antisep- 
sis to  the  greatest  attain- 
able degree. 

Intelligent  after-treatment 
assured. 

Good  nursing  possible. 

Sepsis  always  an  element  of 
danger  but  a  secondary 
amputation  can  be  per- 
formed at  any  time. 


All  the  facts  at  our  command,  together  with  the 
opinion  formed,  should  be  cited  and  the  patient 
must  then  decide  for  himself  which  course  shall 
be  pursued  in  border-line  cases.  The  surgeon,  being 
the  better  judge  of  what  is  required,  however,  should 
advise,  or  even  urge  the  patient  as  to  the  course  to 
be  taken.  Great  comminution  of  bone  with  ex- 
tensive destruction  of  the  tissues,  two  or  more 
compound  fractures  in  the  same  limb  with  rupture 
or  severe  injury  of  the  principal  blood-vessels  and 
nerves,  and  compound  fractures  communicating  with 
large  joints  are  usually  considered  definitely  positive 
indications  for  primary  amputation.  In  spite  of 
this  fact,  occasionally  it  will  be  possible  to  save  a 
limb  in  which  even  one  of  these  conditions  obtains. 
Unless  immediate  operation  is  imperative  to  save  life, 
it  is  advisable  to  afford  the  patient  an  opportunity 
to  rally  from  the  shock  present  before  tmdertaking 
any  operative  measures. 

For  the  technic  of  the  various  amputations  the 
reader  is  referred  to  other  works  on  the  subject. 


up  MINOR  AND  EMERGENCY  SURGERY 

If  conservative  measures  have  been  selected,  all 
efforts  should  be  made  to  convert  the  fracture  into 
a  simple  one  as  soon  as  possible.  Despite  the  kindly 
appearance  of  some  of  these  wounds,  they  must  be 
viewed  with  suspicion,  and  all  compound  fractures, 
including  those  of  the  skull,  must  be  considered  and 
treated  from  the  beginning  as  though  infected. 

Conservative  Surgery  in  Compound  Fractures 
and  Traumatic  Amputations. — To  facilitate  the 
necessary  manipulations  an  anesthetic  is  demanded. 
Blocking  the  main  nerve  trunks  with  cocaine,  as 
advocated  by  Crile  and  others,  is  the  only  method  of 
obtaining  satisfactory  local  anesthesia.  This  also 
prevents  shock  to  a  large  extent,  as  the  injection  of 
a  I  per  cent,  solution  into  the  nerve  trunks  and  peri- 
ostetim  impedes  the  transmission  of  excessive  nerve 
impulses.  Local  anesthesia,  per  se,  does  not  bring 
about  muscular  relaxation  and  its  use  is  consequently 
restricted  to  selected  cases.  In  general,  narcotiza- 
tion will  prove  far  more  satisfactory,  and  if  ether  or 
the  nitrous  oxide-oxygen  combination  be  used  in 
conjunction  with  nerve  blocking,  there  need  be  but 
slight  concern  regarding  subsequent  shock. 

Having  secured  surgical  anesthesia,  the  wound 
should  be  lightly  packed  with  sterile  tampons  to 
protect  the  exposed  tissues  from  any  additional 
traumatism  incidental  to  thorough  cleansing.  The 
entire  part  should  then  be  shaved  and  vigorously 
scrubbed  with  a  moderately  stiff  nail  brush  and 
tincture  of  green  soap.  Following  this,  the  skin  may 
be  rapidly  sterilized  by  irrigating  it  with  an  iodine 
solution:    i    dram   of   the  tincture  to   8  ounces  of 


COMPOUND  FRACTURES  m 

water.  We  are  now  working  in  a  surgically  clean 
field. 

A  sterilized  elastic  tourniquet  applied  just  above 
the  injured  area  maybe  tightened  or  loosened  at  will 
by  an  assistant,  thus  controlling  hemorrhage  that 
may  occur.  The  tourniquet  should  not  be  suffi- 
ciently narrow  to  cut  into  the  skin,  nor  its  applica- 
tion prolonged  unduly. 

The  tampons  are  extracted  and  oil  or  other 
grease  that  may  have  entered  the  wound  is  dissolved 
and  quickly  removed  with  swabs  impregnated  with 
gasoline  or  benzine. 

The  wound  should  now  be  sufficiently  enlarged 
longitudinally  to  permit  a  thorough  inspection  of  the 
damaged  tissues  and  the  removal  with  forceps  of  all 
visible  foreign  material.  Subsequently,  the  tissues  are 
mopped,  but  not  scrubbed,  with  some  disinfectant 
that  permeates  readily.  For  this  purpose  Harrington's 
solution  (hydrargyri  chloridi  corrosivi  gr.  xii,  acidi 
hydrochlorici  5i,  alcoholis  Oii)  is  the  most  efficacioiis. 
A  compound  fracture  should  not  be  roughly  probed 
and  the  operator  should  keep  his  fingers  out  of  the 
wound. 

If  laceration  and  destruction  of  tissues  are  not 
especially  extensive,  the  damaged  areas  may  be 
trimmed  off  and  excised,  but  in  the  more  severe  forms 
the  crushed  parts  are  better  left  until  a  line  of 
demarcation  appears. 

Bone  fragments  must  be  minutely  inspected. 
Pieces  entirely  devoid  of  periosteum  should  be 
removed,  but  no  spicule  having  a  periosteal  attach- 
ment   should   be    disturbed.     The    fragments    may 


11,2  MINOR  AND  EMERGENCY  SURGERY 

be  gently  returned  to  the  most  natural  position  to 
effect  alignment.  The  query  now  arises,  how  can 
we  best  maintain  proper  approximation?  Many 
devices  for  this  purpose  are  at  our  command  but  a 
good  working  rule  is,  the  less  foreign  material 
introduced  the  better.  Occasionally,  fixation  of 
the  fragments  by  uniting  the  periosteum  with 
absorbable  suture  material  and  re-enforced  by  an 
external  dressing  is  all  that  will  be  required.  More 
often  it  will  be  necessary  to  drill  the  bones  and 
fasten  them  together  with  wires  or  bone  plates. 
If  wire  is  chosen,  the  bronze-aluminum  variety 
is  the  most  satisfactory,  being  stronger  and  less 
brittle  than  either  silver  or  iron  wire.  Nails  and 
screws  passing  directly  through  the  bones  are  not 
usually  effective  since  they  soon  loosen  and  thus 
fail  to  fix  the  fragments  firmly  until  union  is  com- 
plete. Lane's  steel  bone  plates,  secured  by  silver 
plated  screws,  are  often  too  rigid  and  unyielding. 
The  silver  bar  devised  and  advocated  by  Sick  comes 
in  lengths  with  holes  for  screws  and  may  be  cut 
any  length  desired.  As  this  is  slightly  pliable  and 
flexible  and  is  easily  removed  later  through  a  small 
incision,  it  is  the  most  desirable  form  of  bone  plate. 

Ruptured  muscles,  nerves  and  blood-vessels 
should  be  accurately  approximated  and  sutured 
with  No.  I  iodine  catgut. 

Drainage  must  always  be  established,  preferably 
at  the  most  dependent  portion  of  the  wound;  the 
ordinary  cigarette  drain  or  fenestrated  rubber  tubing 
will  serve  this  purpose  best.  If  the  anterior  aspect 
of  the  limb  is  the  seat  of  injury,  through-and-through 


COMPOUND  FRACTURES 


113 


drainage  may  be  attained  through  a  stab  wound  on 
the  posterior  surface,  dividing  the  deep  fascia  if 
needs  be. 

The  wound  is  now  loosely  closed  with  interrupted 
sutures  of  silkworm  gut,  great  care  being  exercised 
not  to  constrict  (Fig.  16).  A  heavy  wet  gauze 
dressing  saturated  with  aluminum  acetate  and  ap- 
propriate splints  are  applied  and  the  whole  placed 
in  a  fracture  box.  If  the  wound  has  been  contami- 
nated with  street  dirt  or  gunpowder,  it  is  advisable 


Fig.  16. — ^Wound  sutured  with  through-and-through  drainage 
established. 

to  administer  an  immunizing  dose  of  tetanus  anti- 
toxin subcutaneously  as  a  precaution  against  the 
development  of  tetanus. 

After-treatment  of  compound  fractures  and  trau- 
matic amputations  consists  of  free  drainage  and 
constant  wet  dressings.  The  former  may  be  favored 
by  sprinkling  the  wet  gauze  dressing  with  glycerine 
from  time  to  time  and  daily  irrigation  of  the  wound 
and  drainage  tubes  with  normal  saline  solution  or 
a  watery  solution  of  iodine.  Glycerine  is  a  valuable 
agent  to  keep  the  dressings  moist,  promote  drainage 


114 


MINOR  AND  EMERGENCY  SURGERY 


and  hasten  sloughing.  Continuous  irrigation  of 
the  entire  dressing  with  normal  saline  solution, 
with  a  rubber  sheet  under  the  limb,  is  a  satisfactory 
manner  of  maintaining  saturation  of  the  dressings. 
This  procedure  may  be  easily  accomplished  by 
means  of  a  tin  pail  suspended  above  the  patient 
with  several  small  holes  in  its  bottom,  through  which 
strips  of  linen  have  been  forcibly  pulled.  After 
the  first  week,  more  contusion  often  becomes  ap- 
parent and  continuous  irrigation  should  be  kept 
up  until  sloughing  ceases. 

Progressive  tissue  degeneration  with  clamminess 


Fig.  17. — Fenestrated  plaster-of -Paris  cast  re-enforced  with  metal  bar. 

or  gangrene  of  the  distal  part  or  persistent  hyper- 
pyrexia denotes  that  either  the  blood  supply  is 
inadequate  or  the  septic  process  is  beyond  control. 
Further  efforts  to  save  the  limb  are  then  of  no  avail 
and  a  secondary  amputation  through  sound  tissues 
should  be  performed. 

If,  however,  the  wound  is  evidently  running  an 
aseptic  course  and  the  case  progresses  favorably, 
the  splints  should  be  removed  and  a  fenestrated 
plaster-of-Paris  dressing  substituted  as  soon  as 
sloughing  ceases  and  the  danger  of  sepsis  has  passed. 


COMPOUND  FRACTURES  115 

It  is  best  to  leave  an  aperture  in  the  cast  over  the 
wound  area  during  its  appHcation  rather  than  to 
cut  one  afterward.  The  strength  of  the  dressing 
may  be  greatly  increased  by  incorporating  two 
(one  on  each  side)  metal  bars  with  a  curve  over  the 
fenestration  in  the  center  of  the  plaster  (Fig.  17). 
The  dressings  are  then  continued  through  the  aper- 
ture. Surrounding  the  limb  with  sand  bags  serves 
to  steady  it  and  adds  greatly  to  the  patient's  comfort. 

When  the  granulating  areas  become  visible,  equal 
parts  of  balsam  of  Peru  and  glycerin,  poured  directly 
into  the  wound,  will  keep  the  raw  surfaces  clean  and 
stimulate  reparative  processes.  If  the  denuded 
area  is  extensive,  the  granulations  may  be  covered 
with  skin-grafts  or,  almost  equally  well,  with  the 
external  membrane  found  in  direct  approximation 
with  an  egg  shell,  teased  into  small  pieces  under 
saline  solution,  placed  upon  the  raw  surfaces  and 
covered  with  lint  spread  with  ichthyol  ointment. 
These  dressings  must  be  renewed  daily  if  the  egg 
membrane  is  used  and  at  each  dressing  two  or  three 
little  islands  from  the  previous  one  will  be  found  ad- 
herent. They  are  excellent  foundations  for  the  ulti- 
mate process  of  epithelial  regeneration. 

Passive  motion  and  massage  should  be  commenced 
as  early  as  possible  and  the  further  recovery  of  the 
injured  part  left  to  vis  medicatrix  naturcF. 

Gratifying  success  in  a  large  number  of  cases  with 
the  treatment  outlined  above,  as  has  been  the 
author's  experience,  will  incline  the  surgeon  to  adopt 
a  conservative  attitude  toward  most  cases  of 
compound  fracture  or  traumatic  amputation. 


CHAPTER  VL 
SEQUELiE   OF  FRACTURES. 

Complete  restoration  of  function  and  a  perfect 
cosmetic  result  depend  almost  entirely  upon  in- 
telligent treatment  after  a  fracture  has  been  reduced. 
Although  the  Rontgen  ray  has  demonstrated  that 
mathematical  reduction  of  displaced  bone  frag- 
ments is  rare,  careful  attention  to  details  and  exact 
technic  will  usually  assure  physiologic  restoration 
with  little  or  no  deformity  at  the  injured  site.  Such 
a  result  may  be  considered  eminently  satisfactory. 
Per  contra,  the  surgeon's  misdirected  efforts,  care- 
lessness or  errors  of  judgment  will  eventually  be- 
come manifest  by  delayed  union,  fibrous  union, 
deformed  union,  refracture,  exuberant  callous 
formation,  nerve  involvement,  loss  of  function  (stiff- 
ness, muscular  atrophy,  etc.),  rupture  and  slough- 
ing of  the  skin  and  soft  parts  (converting  the  in- 
jury into  a  compound  fracture),  pressure  sores, 
edema,  ankylosis  or  sepsis. 

When  the  reparative  process  is  retarded  beyond 
that  period  in  which  normal  union  should  occur, 
the  condition  is  known  as  delayed  union.  De- 
ficiency or  slow  development  of  the  provisional 
callus  is  the  etiological  factor  and  may  be  due  to 
either  constitutional  or  local  causes.  Among  the 
former  may  be  mentioned  syphilis,  individual 
dyscrasia,  anemia,  senility,  etc.,  and  the  treatment 

ii6 


SEQUELM  OF  FRACTURES  117 

is  obvious.  The  chief  local  condition  predisposing 
to  delayed  union  is  imperfect  coaptation  of  the  frag- 
ments, due  to  an  incorrect  diagnosis  or  improper 
reduction.  Impairment  of  the  circulation  may- 
result  from  constriction  when  the  retentive  ap- 
pliances are  too  tight  or  to  a  reduction  of  the  blood 
supply  occasioned  by  the  necessary  ligation  of  a 
large  artery.  Premature  motion,  active  or  passive, 
is  frequently  a  cause  and  the  retentive  apparatus 
should  be  permitted  to  remain  sufficiently  long  to 
allow  the  callus  to  solidify  and  union  to  become 
firm,  although  not  long  enough  to  interfere  with  the 
use  of  the  limb.  At  the  same  sime,  too  early  use  of 
the  limb  may  also  delay  the  union.  Operative 
measures  are  optional. 

Non-imion  is  another  term  for  an  ununited  fracture, 
and  in  the  words  of  Stuart  McGuire,  "The  increas- 
ing number  of  cases  of  ununited  fracture  that  come 
to  the  surgeon,  referred  by  the  attending  physician, 
is  a  clear  index  of  the  lack  of  knowledge  possessed 
by  the  average  doctor  with  regard  to  the  treatment 
of  fractures."  In  these  cases  callus  formation  is 
practically  absent  and  the  ends  of  the  fragments 
roimd  off  with  closure  of  the  medullary  canals. 
The  influence  of  constitutional  disturbances  in 
eliminating  callus  formation  is  doubtful,  with  the 
exception  of  syphilis.  Antisyphilitic  treatment  for 
a  few  days  is  never  detrimental  to  the  patient  and 
often  results  in  remarkable  improvement.  This, 
however,  must  not  be  construed  to  mean  neglect  of 
the  patient's  general  condition,  as. the  correction  of 
systemic  errors  is  of  great  importance.     The  local 


ii8  ■       MINOR  AND  EMERGENCY  SURGERY 

causes  of  non-union  are:  persistent  separation  of 
the  fragments,  imperfect  coaptation  with  absence 
of  the  periosteal  bridge,  interposition  of  soft  parts, 
actual  loss  of  bone,  impaired  vascularity  and  sup- 
puration. A  Rontgen  ray  examination  will  dis- 
close many  features  of  the  local  condition,  and  the 
proper  interpretation  of  such  an  investigation  may 
serve  as  a  guide  to  the  intelligent  selection  of  a 
particular  method  of  treatment.  Persistent  separa- 
tion of  the  fragments  results  from  either  failure  to 
overcome  muscular  resistance  or  not  accurately 
approximating  the  fragments  when  applying  the 
fixation  dressing.  This  in  turn  is  most  frequently 
due  to  the  omission  of  anesthesia.  If  the  patho- 
logical conditions  are  present  for  a  sufficiently  long 
time,  it  will  be  necessary  to  resect  the  ends  of  the 
bones,  accurately  adjust  the  freshened  surfaces  and 
maintain  correct  position  by  sutures,  wires  or  some 
other  suitable  material.  Imperfect  coaptation  of 
the  bones  with  absence  of  the  periosteal  bridge  is  often 
followed  by  some  osseous  necrosis  which  requires 
operation  before  satisfactory  union  occurs.  Failure 
to  recognize  the  interposition  of  soft  structures  be- 
tween the  fragments  is  an  inexcusable  error  and 
operative  measures  should  be  instituted  primarily. 
Inability  to  elicit  crepitus,  plus  mobility,  at  the  site 
of  fracture  should  ever  arouse  the  surgeon's  sus- 
picions. Actual  loss  of  bone  occurs  in  some  instances 
of  compound  fractures  and  the  gap  is  best  filled  by 
shortening  of  the  limb  or  transplantation  of  bone. 
Impaired  vascularity  may  be  due  to  disturbances  of 
metabolism  or  to  the  destiniction  of  certain  blood- 


SEQUELM  OF  FRACTURES  119 

vessels,  for  example  anemia  or  loss  of  the  main 
arterial  supply  or  the  nutrient  artery,  when  the 
injury  was  sustained.  Constitutional  treatment 
and  Bier's  method  of  elastic  constriction  to  produce 
hyperemia  are  usually  followed  by  considerable 
improvement.  Suppuration  invariably  interferes 
with  the  reparative  process,  but  after  eliminaton  of 
the  infection  improvement  is  rapid.  Occasionally, 
if  the  suppurative  process  continues  for  some  time, 
it  will  be  necessary  to  expose  the  seat  of  fracture 
and  remove  the  diseased  bone.  Some  surgeons 
recommend  the  injection  of  from  five  to  ten  drops  of 
a  10  per  cent,  solution  of  zinc  chloride  between  the 
bones  and  the  administration  of  lime  salts  as  an  aid 
to  organization  of  callus.  Fifty  per  cent,  alcohol 
has  also  been  used  for  this  purpose.  If  operative 
measures  are  contra-indicated  or  refused  by  the 
patient,  mechanical  apparatus  may  be  advan- 
tageously employed. 

Fibrous  union  is  due  to  failure  of  the  provisional 
callus  to  ossify,  because  the  osteoblasts  do  not 
functionate  properly,  although  the  fibrous  portion 
of  the  union  is  satisfactory.  Owing  to  the  localities 
in  which  fibrous  union  usually  results,  such  as  the 
patella,  olecranon  process  of  the  ulna  and  head  of  the 
femur,  it  is  natural  to  conclude  that  faulty  nutrition 
is  responsible.  An  open  operation  is  the  only 
recourse  and  the  advisability  of  this  procedure  is 
often  questionable,  particularly  in  the  upper  ex- 
tremity. Unless  the  patient  is  a  healthy,  well 
nourished  and  developed  adult,  it  is  better  to  let 


I20  •       MINOR  AND  EMERGENCY  SURGERY 

well  enough  alone  than  to  meddle  with  an  unknown 
quantity. 

Deformed  imion  is  the  result  of  faulty  adjustment 
and  generally  illustrates  an  error  of  omission  or 
commission  on  the  part  of  the  surgeon.  When  due 
to  projection  of  the  tip  of  one  fragment,  the  skin 
may  be  cocainized  and  incised  and  the  offending 
spicule  removed  with  bone  forceps.  If  due  to  poor 
alignment,  resection  and  re-adjustment  are  all  that 
can  be  offered  and  are  almost  always  followed  by 
pronounced  shortening.  So  before  operating  for 
this  condition  it  is  wise  to  hesitate  and  consider: 
of  how  much  definite  improvement  can  the  patient 
be  assured? 

Refracture  is  uncommon  in  a  normal  individual 
but  may  occur  as  the  result  of  too  early  passive  mo- 
tion (subjecting  the  broken  bone  to  strain  or  pressure 
before  union  is  firm),  of  violent  traumatism  and  of 
carelessness  on  the  part  of  the  patient  or  surgeon. 
Anemia,  inadequate  nutrition  and  diminution  of 
inorganic  salts  in  the  economy  are  predisposing 
factors  and  should  be  corrected  by  the  employment 
of  suitable  remedial  agents. 

Exuberant  callus  formation  is  more  common  in 
fractures  occurring  in  new-born  children.  The 
condition  is  an  extremely  painful  one  but  the  prog- 
nosis is  good  and  the  ultimate  result  satisfactory. 
Treatment  is  of  no  avail,  unless  the  callus  mass 
unites  two  parallel  bones;  then  a  portion  may  be 
exsected. 

Nerve  involvements  are  produced  by  injury  to  the 
nerve  at  the  time  of  fracture  or,  later  on,  by  con- 


SEQUELS  OF  FRACTURES  121 

tusion  from  undue  pressure  of  splints,  bandages, 
impinging  callus,  etc.,  or  laceration  caused  by 
mobility  of  the  fragments  where  good  approxima- 
tion is  not  secured  and  maintained.  Contused  and 
slightly  lacerated  nerves  usually  recover  while  the 
fracture  is  knitting,  being  aided  by  the  enforced 
rest,  warmth  of  the  dressing  and  natural  reparative 
process.  Massage,  passive  motion,  electricity  (pre- 
ferably the  galvanic  current)  and  superheated  air 
(400°  F.)  may  hasten  a  tardy  improvement.  When 
the  nerve  is  severely  lacerated  or  divided,  operative 
interference  is  indicated.  To  assure  a  normal 
physiologic  condition  the  operation  should  be  done  as 
early  as  possible,  suturing  the  bone  as  well  as  the 
nerve.  If  the  injury  is  one  of  long  standing,  neuror- 
rhaphy will  be  servicable,  although  the  ulimate  re- 
covery will  be  slow. 

Loss  of  function,  not  due  to  nerve  injuries,  is 
usually  not  a  matter  of  great  consequence.  Removal 
of  the  fixation  dressing,  mobilization,  massage  and 
use  of  the  part  are  sufficient  to  restore  the  impaired 
power.  Once  union  is  firm,  voluntary  action  of  the 
neighboring  muscles  should  be  encouraged. 

The  surgeon  is  seldom  responsible  for  rupture  or 
sloughing  of  the  skin  and  soft  parts  within  the  first 
week  after  the  fracture,  unless  the  wet  dressing  has 
been  omitted,  since  they  are  generally  due  to  con- 
tusion that  was  not  primarily  apparent.  Faulty 
alignment  and  imperfect  immobilization  may  per- 
mit the  rough  margin  of  a  fragment  to  penetrate  the 
skin  and  must  be  corrected  when  they  are  causes. 

Pressure  sores  are  produced  by  an  ill-fitting  plaster 


122.        MINOR  AND  EMERGENCY  SURGERY 

cast  or  insufficiently  padded  splints  and  the  surgeon's 
attention  should  be  attracted  by  complaint  on  the 
part  o£  the  patient.  Manifestly,  the  cast  or  splints 
must  be  removed  and  a  new  dressing  applied. 

Edema  is  always  due  to  failure  to  equalize  the 
pressure  on  the  distal  portion  of  a  limb  and  may  be 
easily  eliminated  by  the  application  of  a  snug  band-  - 
age. 

Ankylosis  occurring  as  a  complication  of  a  fracture 
near  a  joint  is  due  to  peri-articular  thickening  and 
disuse  of  the  joint.  It  is  not  apt  to  be  permanent, 
except  at  the  elbow-  and  knee-joints.  The  treatment 
of  this  condition  has  been  outlined  in  the  chapter  on 
traumatic  injuries  of  joints. 

Sepsis  occurs  after  compound  fractures  only  and 
has  been  discussed  in  Chapter  V.  • 


CHAPTER  VII. 
ACUTE  PYOGENIC  INFECTIONS. 
LOCALIZED  PYOGENIC  INFECTIONS. 

An  abscess  is  the  formation  in  tissue  of  an  abnor- 
mal cavity  containing  pus.  It  is  accompanied  by 
softening  and  sloughing  of  tissue  and,  although  show- 
ing a  tendency  to  encapsulation,  the  suppurative  pro- 
cess will  follow  the  line  of  least  resistance  so  that  the 
purulent  accumulation  may  either  rupture  externally 
or  burrow  deeper  into  the  soft  structures.  Thus, 
if  neglected,  it  may  produce  a  localized  but  gradually 
extending  cellulitis,  septicemia  and  death.  The 
neighboring  lymphatics  are  soon  involved  and 
rapidly  transmit  the  septic  process  to  adjacent 
lymphatic  glands,  lymphangitis,  lymphadenitis  and 
metastatic  abscesses  being  frequent  sequelae.  The 
symptoms  and  physical  signs  of  an  abscess  are  too 
well  known  to  merit  enumeration. 

A  furuncle,  or  boil,  is  a  circumscribed  pyogenic 
infection  of  a  sebaceous  gland  or  hair  follicle,  termi- 
nating in  suppuration  with  a  central  necrotic  mass. 
Because  of  its  superficial  location  a  furuncle  will 
eventually  rupture  through  the  skin  spontaneously 
and  thus  establish  drainage.  The  infection  is  usually 
self -limited,  since  nature  affords  relief  before  the  sup- 
puration progresses  to  any  great  extent.  In  other 
respects  a  furuncle  differs  but  little  from  an  abscess. 

123 


124-         MINOR  AND  EMERGENCY  SURGERY 

A  carbuncle  is  an  acute  phlegmonous  inflammation 
of  the  skin  and  subcutaneous  tissues  with  multiple 
foci  of  necrosis.  The  cellular  tissues  slough  exten- 
sively, the  skin  becomes  indurated  and  dusky  and 
numerous  small  perforations  soon  appear.  Carbun- 
cles nearly  always  occur  on  the  neck  or  back  in 
adults  with  some  constitutional  disturbance,  notably 
diabetes. 

Cellulitis  is  an  inflammation  of  the  loose  connective 
tissue,  invariably  of  bacterial  origin,  due  to  (i)  a 
severe  contusion  or  (2)  an  infected  wotuid.  Unless 
relieved  promptly,  suppuration  is  inevitable.  The 
immediate  complications  are  (i)  extensive  destruc- 
tion of  tissue,  (2)  suppurative  teno-synovitis,  (3) 
lymphangitis  and  (4)  lymphadenitis.  When  treat- 
ment is  neglected  or  misdirected,  the  infection  tends 
to  follow  the  fascia  and  tendon  sheaths,  subsequently 
attacking  the  bone  with  resulting  necrosis.  The 
lymphatics  rapidly  transmit  the  infection  upward, 
toxines  are  absorbed  and  septicemia  and  death  en- 
sue. The  rapidity  with  which  a  cellular  suppuration 
will  sometimes  spread  is  remarkable.  The  severity 
of  the  affection  in  a  given  instance  is,  of  course, 
largely  influenced  by  the  virulence  of  the  micro-organ- 
isms responsible  for  the  infection  and  the  patient's 
resistance  to  bacterial  invasion,  and  the  subsequent 
toxemia.  The  most  reliable  index  of  the  patient's 
antagonistic  power  is  the  leucoc3rtosis  developed. 
The  phenomena  denoting  a  gradually  spreading  cel- 
lulitis are:  (i)  history  of  an  injury  (contusion  or  in- 
fection), (2)  swelling,  (3)  skin  cyanotic  and  edema- 
tous (indicating  partial  circulatory  stasis),  (4)  pain, 


ACUTE  PYOGENIC  INFECTIONS  125 

(5)  tenderness  on  pressure,  (6)  local  heat,  (7)  restricted 
mobility  of  the  part,  (8)  red  and  indurated  super- 
ficial lymphatics,  (9)  upper  limit  of  the  involved 
area  constantly  extending,  and  (10)  evidences  of 
toxic  absorption  (chills,  pyrexia,  increasing  rapidity 
of  the  pulse,  etc.). 

In  all  infectious  conditions  the  presence  of  con- 
stitutional disorders  is  of  paramount  importance. 
For  example,  furunculosis  (intermittent  outbreaks 
of  boils)  and  carbuncles  are  frequently  associated 
with  diabetes,  nephritis,  plethora,  etc.,  and  con- 
sequently a  thorough  urinalysis  should  be  made  in 
all  these  cases.  Obviously,  the  correction  of  sys- 
temic errors  or  disturbances  will  increase  the  patient's 
resistance  to  bacteriemia  and  toxemia. 

Treatment  of  Localized  Pyogenic  Infections. — The 
cardinal  principle  in  the  treatment  of  all  localized 
collections  of  pus  is  to  establish  drainage  immedi- 
ately. Additional  measures  are  also  frequently  in- 
dicated but  without  effecting  a  point  of  exit  for  the 
pus  and  maintaining  free  drainage  the  integrity 
of  the  tissues  still  uninvolved  and  even  the  patient's 
life  may  be  jeopardized.  Every  effort  should  be 
made  to  assist  the  tissues  in  their  effort  to  mitigate 
bacterial  activity. 

Poultices,  devised  by  our  grandmothers,  are 
mentioned  only  to  be  condemned.  Nothing  will 
be  gained  by  waiting  for  "pointing"  except  bacterial 
multiplication.  Even  though  a  poultice  may  en- 
courage spontaneous  rupture  of  the  skin,  it  will  be 
necessary  to  enlarge  the  aperture  and  treat  in  the 
usual  manner.     On  the  contrary,  cold  wet  dressings 


12  6,  MINOR  AND  EMERGENCY  SURGERY 

may  be  of  service  in  the  early  inflammatoiy  stages 
by  relieving  local  congestion.  The  application  of 
antiseptic  solutions  (bichloride  of  mercury  and 
carbolic  acid  usually  being  favored)  with  the  hope 
of  exerting  destructive  influence  on  the  pyogenic 
organisms  is  absurd,  since  no  antiseptic  can  pene- 
trate the  unbroken  skin  sufficiently  to  restrict  germ 
growth.  Were  this  fond  hope  realized,  the  patient 
would  be  poisoned  by  vascular  absorption.  Car- 
bolic dressings  are  particularly  dangerous  because 
of  the  frequency  with  which  poorly  nourished  tissues 
become  gangrenous  from  its  constant  use.  Benefit 
is  derived  from  dressings  saturated  with  plain  water 
or  some  evaporating  lotion,  such  as  equal  parts  of 
alcohol  and  witch  hazel,  simply  because  the  evapora- 
tion assists  the  restoration  of  the  normal  vascular 
equilibrium.  In  exceptional  instances  the  necessity 
for  incision  may  thus  be  obviated. 

As  in  all  other  surgical  procedures,  the  overlying 
and  adjacent  skin  should  be  cleansed  and  the  opera- 
tor's hands  should  be  clean.  This  may  seem  a 
superfluous  injunction,  yet  carelessness  is  the  rule 
rather  than  the  exception. 

Anesthesia  of  the  site  of  incision  should  be  secured 
and  for  this  purpose  the  ethyl  chloride  spray  is  ideal. 
The  container  is  the  only  apparatus  required, 
cutaneous  anesthesia  and  temporary  ischemia  are 
easily  and  quickly  obtained,  there  is  no  additional 
tension  on  the  inflamed  tissues  and  this  method  of 
freezing  is  not  followed  by  sloughing. 

All  incisions  are  preferably  made  parallel  with 
the  course  of  the  blood-vessels  and  the  longitudinal 


ACUTE  PYOGENIC  INFECTIONS  127 

axis  of  the  part.  By  so  doing  profuse  hemorrhage 
will  be  avoided  and  all  possible  sources  of  nutrition 
preserved.  When  the  pus  collection  is  small,  a 
single  incision  should  be  made  directly  over  the 
center  of  the  tumefaction  and  need  be  large  enough 
only  to  allow  free  vent  for  the  pus  and  the  intro- 
duction of  a  small  drain.  Abscesses  situated  near 
large  blood-vessels,  such  as  axillary  abscesses,  are 
best  opened  by  incising  the  skin,  pushing  in  a  pair 
of  closed  hemostatic  forceps  and  withdrawing  them 
open.  In  large  carbuncles  and  extensive  cellulitis 
the  aperture  must  be  larger  or  multiple  incisions 
may  be  made  at  various  points  to  permit  the  estab- 
lishment of  several  channels  of  through-and- through 
drainage.  In  such  instances  some  of  the  deeper 
dense  tissues  should  also  be  divided,  if  the  infection 
appears  to  extend  inward.  Although,  as  a  rule, 
incisions  are  not  required  until  pus  has  formed, 
early  incision  is  often  necessary  to  relieve  tension 
and  the  strangulated  circulation,  thus  preventing 
the  extensive  sloughing  that  follows  steady  intense 
pressure.  It  is  therefore  unwise  to  always  wait 
for  fluctuation  before  incising.  When  the  life  of 
healthy  tissue  is  endangered  by  a  virulent  sup- 
purative process,  such  as  a  cellulitis  due  to  the 
staphylococcus  pyogenes  albus,  it  is  best  to  extend 
the  incision  into  the  sound  region.  The  length  and 
depth  of  the  wounds  are  of  secondary  consideration. 
When  the  cosmetic  results  are  of  special  importance, 
much  can  be  accomplished  in  cases  of  circum- 
scribed pus  collections  with  a  small  incision  followed 
by  active  hyperemia.     The  latter  may  be  obtained 


128  MINOR  AND  EMERGENCY  SURGERY 

by  small  sterile  Bier  suction  cups,  the  rims  being 
lubricated  with  petrolatum,  applied  in  seances  of 
five  minutes  each  with  three  minute  intervals  of 
rest  for  forty-five  minutes.  Much  has  also  been 
claimed  for  passive  hyperemia  as  a  preventive  of 
suppuration  and  as  an  aid  in  limiting  the  infectious 
process,  being  used  in  conjunction  with  drainage, 
after  the  suppuration  has  actually  occurred. 

After  all  incisions,  the  pus  should  be  expressed 
by  exerting  gentle  but  firm  pressure  over  the  sur- 
rounding skin  and  local  bleeding  should  be  encouraged 
for  a  few  minutes.  General  blood-letting  is  contra- 
indicated,  since  it  depresses  the  patient's  vitality 
and  thus  lowers  his  resistance  to  septic  infection. 
Should  the  hemorrhage  appear  excessive  or  be 
unduly  prolonged,  it  may  easily,  be  controlled  by 
packing  the  cavity  temporarily  with  gauze  strips 
wrung  out  in  hot  water.  Bands  of  fascia  and  tendon 
sheaths  must  be  carefully  investigated  and  longitu- 
dinally incised,  if  necessary.  A  probe  should  be 
passed  down  to  the  subjacent  bone  to  exclude 
periosteal  involvement  and  necrosis.  When  a  felon 
exists,  it  should  be  incised  down  to  the  bone. 

Curettage  of  the  cavity  after  pus  evacuation  is 
advocated  and  practised  by  many  surgeons  but  is 
advisable  in  small  abscesses  and  carbuncles  only. 
In  all  other  conditions  it  is  better  to  wait  for  the 
slough  to  separate,  in  order  to  avoid  injuring  areas 
of  normal  tissue.  In  carbuncles  the  -undermined 
skin  areas  should  be  excised  before  curetting. 

To  secure  sterilization,  check  hemorrhage,  hasten 
sloughing    and    stimulate    granulation,    the    cavity 


ACUTE  PYOGENIC  INFECTIONS 


129 


should  be  filled  with  tincture  of  iodine  with  an 
ordinary  medicine  dropper.  This  should  be  per- 
mitted to  remain  undisturbed  for  a  few  minutes 
before  introducing  a  drain.  Pure  carbolic  acid  has, 
also  been  used  for  this  purpose  but  its  use  is  best 
restricted  to  carbuncles.  Some  surgeons  practise 
hypodermic  injections  of  powerful  antiseptic  solu- 


FiG.  18. — Furuncle  on  the  neck  properly  incised  and  drained  with  gutta 
percha  tissue. 

tions  into  or  near  the  affected  region.  These  in- 
jections may  limit  the  inflammation,  yet  they  possess 
the  disadvantage  of  being  extremely  painful  and 
constitutional  poisoning  may  result  therefrom. 

All  infected  cavities  must  be  drained.     Drainage 
does  not   mean   plugging  the  opening  with  gauze, 
but  maintaining  a  free  flow  of  discharge,  be  it  simple 
9 


13° 


MINOR  AND  EMERGENCY  SURGERY 


exudate  or  pus.  Gauze,  plain  or  medicated,  does 
not  drain,  as  is  invariably  demonstrated  by  the 
gush  of  pent  up  pus  that  follows  the  removal  of  a 
gauze  wick.  The  most  satisfactory  drain  for  a 
small  aperture  is  a  little  roll  of  gutta-percha  tissue 
(Fig.  1 8) .  For  larger  openings  and  extensive  slough- 
ing areas  the  fenestrated  rubber  tube  is  the  drain 
par  excellence.  When  through-and-through  drain- 
age is  desired,  the  counter-openings  are  best  made 
by  pushing  a  long  handled  dressing  forceps  under- 


FiG.   19. — Dressing  forceps  pushed  through  incision  and  counter-opening, 
grasping  drainage  tube. 

neath  the  skin  to  the  opposite  side  of  the  part  and 
incising  over  the  tip.  The  jaws  are  then  opened, 
grasp  one  end  of  the  tube  and  withdrawn,  thus 
pulling  the  tube  into  position  (Fig.  19).  Peple  has 
recently  devised  a  serviceable  drain,  consisting  of 
a  split  rubber  tube  into  which  are  sewed  several 
folds  of  rubber  dam.  This  drain  possesses  capillar- 
ity, does  not  become  clogged  and  drains  along  its 
entire  length.  Its  single  objection  is  the  impossibility 
of  irrigation  through  the  tube,  hence  it  cannot  be 
used   when   sloughing   is   extensive. 


ACUTE  PYOGENIC  INFECTIONS 


131 


A  voluminous  wet  dressing  should  cover  all 
infected  parts  and  extend  well  beyond  in  every 
direction.  Plain  water,  normal  saline  solution, 
aluminum  acetate  solution,  alcohol  and  witch  hazel 
or  Burrow's  solution  may  be  used  for  soaking  the 
gauze.  The  particular  agent  selected  is  of  minor 
importance,  provided  the  dressing  is  kept  constantly 
wet.  When  the  patient  is  confined  to  bed  with  a 
large  surface  requiring  attention,  it  is  well  to  employ 
continuous  irrigation.  Saturating  the  dressings  with 
a  hot  watery  solution  of  i  per  cent,  sodium  citrate 
and  4  per  cent,  sodium  chloride,  as  recently 
advocated  by  Wright,  is  an  excellent  method  of 
promoting  drainage.  The  solution  is  hypertonic 
and  stimulates  exudation  by  osmosis.  The  sodium 
citrate  prevents  coagulation  and  scab  formation 
so  that  the  cavity  will  drain  through  a  compara- 
tively small  incision.  The  skin  must  be  smeared 
with  vaseline  or  some  other  emollient  to  prevent 
the  dermatitis  that  might  result  from  its  continuous 
application.  This  solution  is  contra-indicated  if 
there  is  persistent  oozing  and  should  not  be  used  in 
clean  cases  where  profuse  drainage  is  not  essential. 
The  treatment  should  never  be  prolonged  more 
than  three  days  or  healing  will  be  markedly  retarded. 

The  presence  or  absence  of  systemic  disturbances 
in  connection  with  pyogenic  infections  should  be  de- 
termined and  support  will  be  required  to  overcome 
the  debilitating  effect  of  the  septic  element.  Iron, 
arsenic  and  sulphur,  preceded  by  a  calomel  purge, 
are  most  often  used.  The  administration  of  quarter- 
grain  doses  of  calcium  sulphide  every  three  hours 


132 


MINOR  AND  EMERGENCY  SURGERY 


for  a  few  days  exercises  a  beneficial  effect  and  aids 
in    preventing    the    recurrence    of    carbuncles    and 
furuncles. 
After-treatment  of  Localized  Pyogenic  Infections. — 

All  suppurating  cases  should  be  dressed  daily  or 
even  more  often,  until  pus  formation  ceases  and 
granulation  commences.  In  limited  infections  the 
drain  should  be  removed  and  the  sloughs  expressed. 
The  cavity  is  again  filled  with  pure  tincture  of 
iodine,  a  new  drain  inserted  and  a  fresh  wet  dressing 
applied.  In  more  extensive  infections  the  drainage 
tubes  should  be  irrigated  with  hydrogen  peroxide, 
followed  by  the  usual  watery  solution  of  iodine. 
Shreds  of  slough  should  be  excised  and,  if  the  de- 
struction of  tissue  progresses,  new  openings  may  be 
made  and  additional  drainage  tubes  inserted.  At 
each  dressing  the  skin  should  be  cleansed  with  70  per 
cent,  alcohol.  As  the  quantity  of  pus  diminishes, 
the  tubes  may  be  gradually  shortened  and  with- 
drawn. When  the  suppurative  process  has  entirely 
disappeared,  the  pockets  and  cavities  should  be 
loosely  stuffed  with  plain  gauze.  Applications  of  the 
U.  S.  P.  boric  acid  ointment  or  10  per  cent,  ichthyol 
are  of  use  in  the  after-treatment  of  boils  and  car- 
buncles after  the  wet  dressings  are  discontinued. 

SYSTEMIC  PYOGENIC  INFECTIONS. 

Systemic  infections  are  sequels  resulting  from 
local  bacterial  invasions,  due  to  the  absorption  of 
the  toxines  and  endotoxines  of  the  invading  bacteria, 
and  are  characterized  by  grave  constitutional  disturb- 
ances.    The  intoxication  may  occur  as  a  sapremia, 


ACUTE  PYOGENIC  INFECTIONS  133 

bacteriemia,  septicemia,  toxemia  or  pyemia,  but 
it  is  almost  unnecessary  to  make  a  minute  dis- 
tinction, since  the  manifestations  of  the  various  types 
are  similar  in  almost  every  respect  and  the  treatment 
is  much  the  same.  The  clinical  phenomena  evidenc- 
ing a  constitutional  intoxication  are :  presence  of  local 
suppuration,  hyperpyrexia  (more  elevation  in  the 
evening) ,  chills,  flushed  cheeks,  increased  pulse  rate, 
digestive  disturbances,  sweating,  prostration,  urinary 
changes  and  sometimes  dehrium  or  coma.  Any  or 
all  of  these  manifestations  may  be  present.  Py- 
emia is  characterized  by  the  formation  of  metastatic 
abscesses.  Unless  efficient  treatment  is  instituted 
promptly,  death  soon  occurs. 

Treatment  of  systemic  infections  consists  of  (i)  re- 
moval of  the  source  of  absorption  and  disinfection  of 
what  cannot  be  removed,  (2)  serotherapy,  (3)  pro- 
moting elimination  by  stimulating  the  emunctories, 
and  (4)  combating  the  constitutional  symptoms  by 
supporting  the  patient's  vitahty  with  nourishing 
foods  and  suitable  tonics. 

The  first  is  obtained  by  emptying  and  disinfecting 
all  the  original  foci  of  suppuration,  as  described  in  the 
previous  paragraphs  of  this  chapter.  This  in  itself 
often  suffices  to  cause  the  disappearance  of  toxic 
symptoms,  by  arresting  the  propagation  of  bacteria. 
In  pyemia,  if  a  suppurative  lymphadenitis  exists, 
the  glands  should  be  completely  excised. 

Serum-therapy  is  now  being  accorded  considerable 
attention  as  a  method  of  combating  profound  tox- 
emias and  good  results  are  often  obtained  from  the  use 
of  antitoxines  and  vaccines,  particularly  in  strepto- 


134 


MINOR  AND  EMERGENCY  SURGERY 


COCCUS  and  staphylococcus  infections.  When  the  ser- 
vices of  a  capable  pathologist  can  be  secured  and  the 
necessary  facilities  are  at  hand,  it  is  better  to  manu- 
facture an  autogenous  vaccine  than  to  employ  a  stock 
preparation.  This  will  also  avoid  any  possible  error 
that  might  be  made  regarding  the  identity  of  the 
organism  responsible  for  the  infection. 

The  excretory  organs  must  be  kept  active  to  pro- 
mote elimination.  Drugs  administered  per  os  are  to 
be  avoided,  as  they  may  further  irritate  the  already 
disturbed  stomach.  Hydrotherapy  has  distinct  value 
but  hot  packs  are  contra-indicated  because  they 
tend  to  depress  the  patient's  limited  vitality.  The 
patient  must  be  given  absolute  rest  in  bed  and  sur- 
rounded with  hot-water  bags  to  induce  perspiration. 
Physiologic  saline  solution,  given  hypodermatically, 
as  an  enema  or  intravenously,  markedly  aids  elimina- 
tion, as  well  as  serving  as  a  circulatory  stimulant. 
The  author  has  derived  extremely  satisfactory  re- 
sults from  an  enema  consisting  of  4  ounces  of  magne- 
sium sulphate  dissolved  in  a  pint  of  cool  water  (70°  F.) , 
repeated  every  two  hours  until  improvement  is  pro- 
nounced. Rapid  elimination  of  toxines  is  brought 
about  by  the  osmotic  action  of  this  solution,  which  at 
the  same  time  causes  free  catharsis.  The  low  tem- 
perature serves  to  reduce  pyrexia.  Persistent  vom- 
iting is  not  rare  and  can  be  relieved  by  gastric 
lavage. 

The  food  should  be  nourishing  and  easily  digested. 
Coffee,  alcoholic  stimulants,  broths  and  milk  will 
usually  suffice.  When  the  stomach  has  been  washed 
out,  the  patient  may  be  fed  per  rectum  for  a  few 


ACUTE  PYOGENIC  INFECTIONS 


^35 


days.  Later,  a  few  well  selected  tonics  may  be 
cautiously  introduced.  The  tincture  of  the  chloride 
of  iron  and  the  freshly  made  elixir  of  iron,  quinine 
and  strychnine  are  excellent  preparations.  The 
cardio-vascular  depression,  which  is  always  present 
to  a  variable  degree,  may  be  ameliorated  by  inhala- 
tions of  oxygen. 

SPECIAL  INFECTIONS. 

Among  the  special  forms  of  infection  frequently 
encountered  may  be  mentioned  erysipelas,  tetanus, 
anthrax,  malignant  edema  and  glanders.  None  of 
these  are  true  pyogenic  infections,  yet  for  the  sake  of 
convenience  the  first  two  will  be  considered  here. 

Erysipelas  has  been  clinically  subdivided  into 
phlegmonous,  facial  and  the  erysipelatoid  lymphan- 
gitis of  Rosenbach.  There  exists  some  diversity 
of  opinion  regarding  the  exact  identity  of  the  organ- 
ism causing  erysipelas  but  it  is  universally  acknowl- 
edged that  it  is  due  to  a  streptococcus  invasion. 
The  three  disease  types  are  practically  alike  except 
for  the  variation  in  the  intensity  of  the  infection. 
The  phlegmonous  form  is  a  severe  one,  the  facial 
milder  and  the  erysipelatoid  lymphangitis  is  a 
condition  found  almost  exclusively  on  the  hands. 
The  subjective  and  objective  signs  of  erysipelas  are 
too  well  known  to  require  reiteration;  the  disease 
may  run  a  benign  or  malignant  course,  depending 
upon  the  virulence  of  the  bacterial  invasion. 

All  cases  of  erysipelas  should  be  completely  isolated, 
as  a  mild  infection  in  one  patient  may  be  transmitted 


136  MINOR  AND  EMERGENCY  SURGERY 

to  another  in  a  profoundly  septic  form.  Attendants 
should  wear  rubber  gloves  for  self -protection. 

Local  applications  of  suitable  medicaments  rapidly 
check  the  spread  of  the  disease  and  hasten  resolution, 
so  that  the  painful  measures  often  recommended, 
such  as  sacrification  and  intradermal  injections, 
are  usually  unnecessary.  The  three  most  efficient 
remedial  agents  are  iodine,  ichthyol  and  carbolic 
acid.  Irrespective  of  the  agent  selected,  the  local 
applications  must  always  extend  half  an  inch  to  an 
inch  beyond  the  margin  of  the  eruption.  Iodine 
is  best  applied  in  the  form  of  the  tincture ;  ichthyol, 
2  drams  dissolved  in  i  ounce  each  of  alcohol  and 
ether;  and  carbolic,  painted  on  the  surface  until 
whitened  and  followed  by  the  liberal  use  of  alcohol. 

Constitutional  treatment  is  of  the  utmost  import- 
ance in  these  cases,  as  the  patient's  powers  of  resist- 
ance are  poor.  The  regime  to  be  followed  is  es- 
sentially the  same  as  that  in  systemic  infections. 

For  some  reason,  as  yet  not  satisfactorily  explained, 
an  attack  of  erysipelas  occasionally  exerts  a  favorable 
and  curative  influence  on  certain  intercurrent  condi- 
tions. For  example,  various  writers  have  reported 
that  sarcomata  have  entirely  disappeared  after  an 
attack  of  erysipelas.  In  an  attempt  to  produce  these 
results,  sarcomatous  patients  have  been  intention- 
ally inoculated  with  the  toxines  of  the  streptococcus 
of  erysipelas  and  a  certain  degree  of  sucess  has  been 
claimed  by  some  authors.  To  increase  the  potency 
of  the  preparation,  the  toxines  of  the  bacillus  pro- 
digiosus  are  added,  this  product  being  known  as 
Coley  fluid. 


ACUTE  PYOGENIC  INFECTIONS  137 

Tetanus  is  an  infectious  disease  due  to  the  bacillus 
tetani,  characterized  by  violent  and  persistent 
tonic  spasms  of  the  voluntary  muscles,  particularly 
those  of  the  lower  jaw,  and  sometimes  accompanied 
by  local  paralysis.  Distinct  intermittent  exacerba- 
tions are  usually  present.  The  infection  originates 
in  wounds,  especially  those  of  the  extremities,  and 
is  due,  as  a  rule,  to  contamination  with  actual  dirt. 
Unlike  the  ordinary  pyogenic  infections,  the  invasion 
of  bacilli  tetani  does  not  interfere  with  primary 
union,  hence  the  initial  symptoms  are  not  local  but 
general.  In  man,  the  rigidity  usually  begins  in  the 
masseter  and  posterior  cervical  muscles,  progressing 
downward  from  the  head,  and  may  be  followed  by 
persistent  opisthotonos.  The  toxines  are  intensely 
virulent  and  the  period  of  incubation  may  vary  from 
one  to  twenty  days.  Upon  the  duration  of  the 
period  of  incubation,  the  prognosis  may  be  safely 
based.  In  cases  exhibiting  a  short  period  of  in- 
cubation (one  to  eight  days)  a  fatal  termination 
may  be  anticipated,  while  in  the  milder  cases 
(twelve  to  twenty  days)  recovery  may  be  expected, 
in  spite  of  the  fact  that  the  course  of  the  disease  is 
apt  to  be  prolonged.  Cases  developing  between 
the  eighth  and  twelfth  days  after  the  injury  may 
terminate  in  either  recovery  or  death  and  are  un- 
doubtedly influenced  to  a  greater  extent  by  appro- 
priate remedial  measures  than  are  those  of  the 
other  two  classes.  These  statements  are  verified 
by  experience  and  careful  investigation  of  the  records 
of  a  large  number  of  cases  of  tetanus,  occurring  be- 
fore as  well  as  after  the  introduction   of  tetanus 


13,8  MINOR  AND  EMERGENCY  SURGERY 

antitoxine  as  a  curative  agent.  The  sympto- 
matology of  tetanus  is  distinctive  and  will  not  be 
elaborated  here. 

The  most  efficient  method  of  treatment  is  pro- 
phylaxis, which  consists  of  thorough  disinfection 
of  all  wounds,  removal  of  sloughs,  foreign  bodies 
and  other  extraneous  matter,  and  drainage.  All 
cases  of  gunshot  wounds  and  those  contaminated 
with  street  dirt,  especially  the  dirt  from  asphalt 
pavements,  should  be  given  a  prophylactic  sub- 
cutaneous injection  of  from  lo  to  20  c.c.  of  tetanus 
antitoxine  just  above  the  wound.  When  the  tetanic 
condition  has  once  become  established,  the  anti- 
toxine must  be  administered  within  twenty-four 
hours  to  be  of  material  service.  It  should  be 
generously  used:  20  c.c.  injected  along  the  nerve 
sheaths  above  the  site  of  injury,  10  c.c.  thrown 
into  the  cerebro-spinal  axis  (usually  a  subdural 
injection)  and  20  c.c.  used  for  moistening  the  dress- 
ing covering  the  wound.  The  injections  may  be 
repeated  every  twelve  hours  if  necessary  and  the 
patient's  condition  permits.  Although  the  anti- 
toxine usually  has  but  little  effect  upon  those  viru- 
lent cases  with  a  short  incubation  period,  its  use 
should  not  be  discouraged.  Needless  to  say,  the 
antitoxine  should  always  be  used  reasonably  fresh. 

Some  surgeons  have  employed  a  solution  of 
magnesium  sulphate  as  an  antitetanic  remedy  with 
marked  success  in  many  instances.  Like  antitoxine, 
it  is  administered  by  injection  into  the  cerebro- 
spinal axis.  However,  it  should  not  be  accepted 
as  a  substitute  for  antitoxine. 


ACUTE  PYOGENIC  INFECTIONS 


139 


To  palliate  the  paroxysmal  exacerbations,  anti- 
spasmodics and  hypnotics  are  useful.  Chloroform 
inhalations  and  5 -grain  doses  of  chloretone  have 
the  most  favorable  action,  especially  if  re-enforced 
with  quarter-grain  hypodermic  doses  of  morphine. 
The  patient  should  be  confined  to  bed  in  a  dark 
room  and  fed  through  a  soft-rubber  catheter  passed 
into  the  pharynx  through  the  nose.  Catheterization 
and  enemata  are  usually  necessary  to  relieve  the 
retention  of  urine  and  feces.  There  can  be  no 
objection  to  the  adoption  of  other  therapeutic 
measures  that  may  be  required. 


CHAPTER  VIII. 


EFFECTS  OF  INTENSE  HEAT  AND  COLD. 


Classification : 


Extent 


Causative 
factors 


BURNS. 


1.  First  degree:  simple  hyperemia. 

2 .  Second  degree :  dermatitis  with  vesication. 

3.  Third  degree:  eschars,  gangrene  and 
carbonization,  involving  subcutaneous 
structures. 

1.  Contact  with  flames  and  intense  heat. 

2.  Contact  with  hot  liquids  or  steam  (scalds). 

3.  Contact  with  electric  currents. 

4.  Prolonged  exposure  to  solar  rays. 

5.  Lightning  stroke. 

6.  Rontgen  ray  burns. 

7.  Chemical  (concentrated  acids  and  caustic 
alkalies) . 


The  extent  of  the  destruction  of  tissue  depends 
upon  the  temperature  of  the  radiant  heat,  duration 
of  contact,  superficial  diffusion  of  the  heated  object 
or  fluid,  and  density  of  the  area  burned.  In  severe 
cases,  the  constitutional  effects  are  pronounced 
and  the  alleviation  of  these  associated  conditions 
is  of  even  more  importance  than  the  local  treatment 
of  the  burn  itself.  Shock  and  nephritis  are  almost 
constant  concomitant  factors,  and  suppuration, 
sepsis  and  secondary  hemorrhage  not  infrequent 
ones.  The  symptoms  may  be:  (i)  pain,  (2)  rest- 
lessness,   (3)  frequent  micturition,  (4)  cold  extremi- 

140 


EFFECTS  OF  INTENSE  HEAT  AND  COLD     141 

ties,  (5)  small  and  rapid  pulse,  (6)  persistent  thirst, 
(7)  edema,  (8)  prostration,  (9)  collapse  and  (10) 
unconsciousness.  If  a  large  surface  is  burned  or 
scalded,  the  excretory  function  of  the  skin  is  mark- 
edly impaired  and  it  is  necessary  for  the  kidneys 
to  compensate  for  the  sudden  diminution  in  toxic 
elimination  by  the  skin.  Being  often  unable  to  im- 
mediately cope  with  this  emergency,  congestion  and 
nephritis  soon  follow.  In  fact,  it  has  been  stated, 
and  confirmed  by  experience,  that  even  burns  of 
the  first  or  second  degree  extending  over  one-third 
or  more  of  the  body  surface  interfere  with  the  ex- 
cretory function  of  the  skin  to  such  an  extent  that 
these  cases  rarely  recover;  the  majority  die  of  shock 
within  twenty-four  hours.  Burns  of  the  third  degree 
are  also  influenced  by  the  extent  of  the  region 
destroyed  and  the  depth  to  which  the  tissues  are 
disorganized.  Although  the  patient  may  frequently 
lose  consciousness  and  later  regain  his  mentality, 
instantaneous  death,  from  the  arrest  of  cardiac  and 
respiratory  action,  is  a  common  occurrence  from 
contact  with  heavily  charged  electric  wires  and 
lightning.  Traumatic  neuroses  occasionally  follow 
these  injuries.  An  ^-ray  bum  is  a  peculiar  lesion 
in  itself,  characterized  by  a  stubborn  dermatitis, 
ulceration  of  the  skin,  and  painful  and  tedious  re- 
covery. If  extensive,  amputation  may  be  necessary. 
A  number  of  deaths  have  occurred  as  the  result  of 
frequent  or  prolonged  exposure  to  the  x-rsij,  but 
with  universal  recognition  of  its  dangers,  improved 
technic  and  restriction  of  its  use  to  those  skilled 
in  its  application,  these  injuries  are  now  infrequently 


142  MINOR  AND  EMERGENCY  SURGERY 

observed  and  before  long  should  become  a  rarity. 
The  mortality  from  burns  is  particularly  high  in 
infants  and  young  children. 

Local  Treatment  of  Bums. — ^The  local  applica- 
tions appropriate  in  a  given  instance  will  vary  ac- 
cording to  the  severity  and  extent  of  the  burn. 

The  pain  incident  to  bums  of  the  first  degree  is 
immediately  relieved  by  applications  of  a  saturated 
solution  of  either  sodium  bicarbonate  or  picric  acid. 
Several  layers  of  gauze  should  be  saturated  with  the 
solution  and  wrapped  around  the  burned  area. 
Later,  dressings  of  petroleum  ointment  may  be  sub- 
stituted. Since  burns  of  the  first  degree  leave  no 
scar,  they  are  of  relatively  small  consequence.  Bums 
due  to  exposure  to  the  sun  are  best  treated  with 
applications  of  bicarbonate  of  soda  solution,  followed 
by  some  simple  emollient,  such  as  vaseline  or  almond 
oil. 

Burns  of  the  second  degree  are  nearly  always 
accompanied  by  the  formation  of  vesicles  or  blebs 
and  to  avoid  injuring  them  the  clothing  should  be 
carefully  cut  away.  Exposure  to  air  is  to  be  avoided 
and  one  area  should  be  dressed  before  another  is  im- 
covered.  Asepsis  will  thus  be  maintained  and  a 
rapid  uncomplicated  recovery  will  ensue.  The  sur- 
face maybe  cleansed  by  gentle  irrigation  with  warm 
sterile  water  and  the  belbs  punctured  at  their  base 
tvith  a  sterile  needle  to  allow  the  extravasated 
serum  to  escape.  The  epidermis,  however,  should 
not  be  disturbed  or  removed,  since  it  protects  the 
denuded  papillae.  Burns  of  this  class  are  often 
infected  through  careless  technic  and  asepsis  is  im- 


EFFECTS  OF  INTENSE  HEAT  AND  COLD 


143 


portant.  There  exists  some  difference  of  opinion 
regarding  the  applications  to  be  employed  in  these 
cases.  Various  writers  have  claimed  good  results 
from  the  sole  use  of  either  dusting  powders,  emol- 
lients or  wet  dressings.  All  are  of  value  under  certain 
conditions  but  no  single  one  should  be  utilized  to  the 
exclusion  of  the  others.  Given,  a  recent  uninfected 
bum  with  preservation  of  the  epidermis,  a  mixture 
of  one  part  acetanilid  and  three  parts  boric  acid, 
dusted  in  a  thick  layer  over  the  burn  and  covered 
with  gauze,  will  prevent  infection  and  promote 
rapid  recoveiy.  These  dressings  should  be  left 
undisturbed  as  long  as  possible.  If  the  burn  is 
extensive  and  the  belbs  have  already  ruptured, 
leaving  numerous  raw  surfaces,  carron  oil  (a  mixture 
of  equal  parts  of  lime  water  and  raw  linseed  oil) 
will  relieve  the  pain  and  soothe  the  irritation  follow- 
ing the  contact  with  air.  This  is  the  remedy  most 
often  employed  in  emergency  work  and  is  indeed  an 
excellent  temporary  dressing.  Later  on,  the  margins 
of  the  belbs  may  be  trimmed,  extraneous  material 
removed  and  the  denuded  surfaces  carefully  dried  by 
sponging  with  sterile  gauze  and  mopping  with 
tincture  of  iodine,  and  a  10  per  cent,  ointment  of 
boric  acid  applied.  A  5  per  cent,  ointment  of  ich- 
thyol  is  also  frequently  used  but  is  inferior  to  the 
boric  acid,  except  in  the  presence  of  inflammation. 
When  epidermization  begins,  the  U.  S.  P.  ointment 
of  zinc  oxide  should  be  substituted.  If  a  bum  does 
not  present  for  treatment  until  considerable  time  has 
elapsed  and  the  area  is  already  infected,  wet  dress- 
ings  are   of   service.     Fomentations    of    Thiersch's 


1 44  MINOR  AND  EMERGENCY  SURGERY 

solution^  or  normal  saline  solution  should  be  con- 
stantly applied  until  the  granulations  become 
healthy,  and  then  followed  by  the  boric  acid  oint- 
ment. The  indications  for  redressing  burns  are: 
(i)  rise  of  temperature,  (2)  local  pain,  (3)  odor  and 
(4)  soiled  dressings.  The  treatment  of  burns  by 
omitting  all  coverings  except  a  dusting  powder, 
thereby  constantly  exposing  the  surfaces  to  the  air, 
and  frequent  mopping  of  the  extruded  sei^um  has 
been  recently  advocated.  The  results  in  the  few 
cases  in  which  the  author  has  employed  this  method, 
however,  have  not  been  encouraging. 

Burns  of  the  third  degree  are  always  dangerous 
injuries  because  subsequent  sloughing  is  profuse  and 
complications  are  the  rule.  Electric  burns  are 
almost  invariably  of  this  class  and  are  characterized 
by  absence  of  pain  and  slow  healing.  While  com- 
bating the  constitutional  effects  and  complications 
is  of  paramoimt  importance,  this  dictum  must  not 
be  construed  to  excuse  neglect  of  the  local  treatment. 
The  objective  points  are  to  secure  rapid  separation 
of  the  slough  and  prevent  sepsis.  The  constant 
warm  bath  (100°  F.)  of  normal  saline  solution,  which 
has  been  more  widely  employed  abroad  than  in 
this  coiintry,  is  an  efficient  method  of  treatment. 
It  should  be  continued  until  healthy  granulations 
appear.  Dressings  of  equal  parts  of  balsam  of  Peru 
and  glycerine  likewise  hasten  separation  of  the  slough 
in  restricted  areas.     The  dressings  should  be  changed 

'  Thiersch's  solution: 

Salicyhc  acid 3  ss 

Boric  acid 3  iii 

Sterile  water O  ii 


EFFECTS  OF  INTENSE  HEAT  AND  COLD     145 

daily  and  the  wound  irrigated  with  hydrogen  per- 
oxide. As  the  shreds  of  necrotic  tissue  loosen,  they 
may  be  excised  with  scissors.  Iodine  is  then  dropped 
into  the  wound  to  cleanse  it.  When  granulation  be- 
gins, the  surfaces  should  be  touched  with  a  i  per 
cent,  solution  of  copper  sulphate,  to  stimulate  the 
regeneration  of  tissue.  As  the  healthy  tissue  ap- 
proaches the  surface,  healing  will  be  accelerated  and 
cicatricial  contraction  obviated  by  employing 
Thiersch's  skin-grafts  or  transplanting  skin-flaps.  In 
addition,  the  position  which  puts  the  surface  of  the 
part  on  the  stretch  wih  tend  to  diminish  the  skin 
deformity  by  temporarily  enlarging  the  surface. 

Burns  due  to  chemical  agents,  such  as  strong  acids 
and  alkalies,  must  be  treated  by  the  chemical  antidote 
for  that  which  has  produced  the  excoriation.  Weak 
alkalies  are  indicated  in  burns  due  to  acids,  and 
vice  versa. 

X-ray  bums,  if  painful  and  extensive,  usually 
require  excision  of  the  ulcerated  areas  or  amputation, 
as  they  are  absolutely  resistant  to  ordinary  methods 
of  treatment.  Curettage  of  the  ulcers,  followed  by 
skin-grafting,  will  occasionally  cure. 

Obviously,  any  burn  sufficiently  severe  to  destroy 
the  blood  supply  and  bone  of  a  part  necessitates 
amputation. 

Treatment  of  the  Constitutional  Effects  and  Com- 
plications of  Burns. — In  all  cases  of  burns  the  indi- 
cations are:  (i)  to  relieve  pain  and  overcome  shock, 
(2)  to  guard  against  visceral  congestion,  and  (3)  to 
counteract  the  exhaustion  incident  to  continual 
pain  and  suffering  or  sepsis. 


146  MINOR  AND  EMERGENCY  SURGERY 

All  cases  of  extensive  burns  should  immediately 
receive  sufficient  morphine  hypodeimatically  to  re- 
lieve pain.  One  quarter  of  a  grain  usually  alleviates 
pain,  supports  the  heart,  and  quiets  the  patient, 
but  it  may  be  repeated  as  often  as  necessary.  It 
should  not  be  combined  with  atropine  as  the  latter 
arrests  glandular  activity.  The  patient  should  be 
placed  in  bed,  surrounded  with  hot  water  bottles  and 
kept  absolutely  quiet.  All  severe  burns  are  accom- 
panied by  marked  shock  and  every  effort  should  be 
made  to  establish  reaction  as  soon  as  possible.  For 
details,  the  reader  is  referred  to  the  chapter  on 
surgical  shock.  In  cases  of  electric  shock,  artificial 
respiration  and  hypodermic  injections  of  strychnine 
and  atropine  should  be  employed. 

Inflammation  of  any  of  the  viscera  may  occur  and 
give  rise  to  alarming  symptoms.  Of  the  involve- 
ments, renal  congestion  appears  first  and  is  evidenced 
by  albuminuria,  as  well  as  the  other  urinary  findings 
of  nephritis.  The  most  efficient  remedy  in  such  con- 
ditions is  2  drams  of  liquor  ammonii  acetatis, 
administered  in  a  half  a  glass  of  ice  water  every 
two  hours.  This  relieves  thirst,  promotes  diuresis 
and  depletes  the  congestion.  Constipation  is  not 
imusual  and  is  ordinarily  relieved  by  some  simple 
laxative,  such  as  castor  oil.  Inflammation  and 
ulceration  of  the  gastro-intestinal  mucosa  is  fre- 
quently but  another  manifestation  of  visceial  con- 
gestion and  may  be  followed  by  diarrhea,  perforation 
and  death.  In  such  cases,  opium,  gallic  acid,  bis- 
muth and  other  intestinal  astringents  are  ser- 
viceable. 


EFFECTS  OF  INTENSE  HEAT  AND  COLD     147 

Many  patients  who  survive  the  initial  shock 
accompanying  a  severe  burn  will  die  later  of  exhaus- 
tion. For  instance,  it  is  not  unusual  for  a  case  of 
third  degree  electric  burn  of  the  back  to  apparently 
progress  favorably  for  a  week  or  more  and  then 
slowly  die  of  exhaustion.  The  indications  are: 
to  (i)  allay  pain  with  repeated  hypodermic  injec- 
tions of  morphine,  (2)  maintain  asepsis  of  the  in- 
jured area,  (3)  hasten  sloughing  and  repair,  (4)  guard 
against  complications,  such  as  nephritis,  pneumonia, 
vomiting,  diarrhea  and  cerebral  congestion,  and 
(5)  support  the  patient's  vitality  with  a  nutritive 
diet  and  suitable  tonics. 

SUNSTROKE. 

While  not  properly  within  the  domain  of  surgery, 
insolation  and  heat  exhaustion  so  frequently  pre- 
sent as  emergencies,  particularly  to  the  ambulance 
surgeon,  that  their  consideration  here  may  not  be 
amiss.  It  is  of  the  utmost  importance  to  differen- 
tiate these  two  varieties  of  sunstroke,  as  the  former 
represents  a  disturbance  of  the  heat  regulating  centers 
due  to  the  toxemia  from  the  excessive  heat,  while 
the  latter  depends  on  a  vasomotor  paralysis  with 
marked  circulatory  disturbances  in  the  brain  and 
body  surface.  The  treatment  appropriate  for  one 
is  practically  that  which  is  contra-indicated  for  the 
other.  To  distinguish  between  the  two,  the  follow- 
ing phenomena  should  be  observed : 


I4& 


MINOR  AND  EMERGENCY  SURGERY 


Insolation. 

Patient  insensible. 

Coma;  sometimes  delirium 
and  convulsions. 

Face  flushed. 

Skin  dry  and  burning. 

Respirations  rapid  and  shal- 
low. 

Pulse  rapid  and  full. 

Temperature  105°  to  110°  F. 


Suppression 

action. 
Prognosis  guarded 


of     glandular 


Heat  Exhaustion. 
Patient  dazed. 
Weakness  and  prostration;  not 

unconscious. 
Face  pale. 
Skin  cool. 
Respirations  stertorous. 

Pulse  rapid  and  feeble. 
Temperature    normal    or    sub- 
normal. 
Perspiration  increased. 

Prognosis  good. 


Treatment  of  Sunstroke.- -In  all  cases  of  insolation 
a  gag  should  be  inserted  between  the  jaws,  to  prevent 
the  patient  from  biting  his  tongue.  In  emergencies, 
a  wooden  wedge  will  answer  the  purpose .  The  hyper- 
pyrexia must  be  reduced  as  rapidly  as  possible  and 
hydrotherapy  will  accomplish  this  better  than  any- 
thing else.  Clothing  should  be  removed  and  the 
patient  placed  in  a  cold  water  bath  at  a  temperature 
of  about  75°  F.,  with  an  ice  bag  applied  to  the  head. 
Ice  should  be  gradually  added  to  the  water  until  a 
temperature  of  50°  F.  is  reached.  Restlessness  and 
convulsions  may  require  morphine.  When  the  pa- 
tient is  returned  to  bed,  he  should  be  enveloped  in  a 
cold  pack  with  a  hot-water  bottle  at  the  feet,  and  cold 
(70°  F.)  saline  enemata  may  be  given  to  prevent 
subsequent  recurrence  of  fever.  Antipyrine  and 
blood-letting  will  also  often  prove  useful.  Should 
the  patient  recover,  he  must  be  warned  as  to  his 
inability  to  withstand  high  temperatures  during  the 
rest  of  his  life. 


EFFECTS  OF  INTENSE  HEAT  AND  COLD.      149 

The  treatment  of  heat  exhaustion  is  essentially 
that  of  mild  shock.  The  patient  should  be  placed  in 
bed,  surrounded  with  hot  water  bottles  and  covered 
with  warm  blankets.  Ammonia,  strong  coffee  and 
hypodermic  injections  of  adrenalin  chloride  are  the 
most  efficient  stimulants. 

CHILBLAIN. 

Chilblain  is  a  condition  following  exposure  to  in- 
tense cold  and  is  characterized  by  pruritis,  local  con- 
gestion and  a  tendency  to  teiTninate  in  gangrene. 
It  is  due  to  a  too  sudden  application  of  heat  following 
the  freezing  of  the  part,  occasioning  an  unduly  rapid 
reaction.  "Frost-bite"  has  been  used  as  a  synony- 
mous term  but  its  use  should  be  restricted  to  designate 
the  initial  freezing  of  the  tissues  only.  The  consti- 
tutional effects  of  exposure  to  intense  cold  are  often 
pronounced. 

Treatment  of  Chilblain. — The  general  effects  of  cold 
should  be  combated  by  overcoming  the  general  de- 
bility and  improving  the  circulation,  by  friction  and 
artificial  respiration.  The  best  method  of  local  treat- 
ment for  chilblain  is  prophylactic  and  this  consists  of 
avoiding  contact  with  heat,  rubbing  the  chilled  parts 
with  snow  or  cold  water  and  gradually  raising  the 
surrounding  temperature  until  the  natural  color  is 
restored,  thereby  establishing  a  slow  reaction.  The 
frozen  areas  may  be  covered  for  a  time  with  cloths 
soaked  in  cold  water.  If  the  surfaces  are  not 
abraded,  the  skin  should  be  painted  with  equal  parts 
of  tincture  of  iodine  and  tincture  of  opium,  or  an  oint- 
ment of  ichthyol   and   lanoline   applied.     If  blebs 


I50-        MINOR  AND  EMERGENCY  SURGERY 

form,  they  should  be  punctured.  For  broken  chil- 
blains, Gardiner  recommends  the  following  ointment : 

Hydrargyri  ammoniati .      gr.  v 

Ichthyolis ttl  x 

Amylis, 

Zinci  oxidi • aa  5  ii 

Petrolatum , §  ss 

Misce. 

If  the  tissues  become  gangrenous,  the  treatment 
should  be  based  on  general  principles.  It  will  oc- 
casionally be  necessary  to  amputate  a  portion  of  an 
extremity.  Massage  and  suitable  exercises  are  use- 
ful in  the  after-treatment. 


CHAPTER  IX. 

ULCERS— BED-SORES. 
ULCERS. 

An  ulcer  is  an  excavated  loss  of  continuity  upon 
the  body  surface,  a  circumscribed  area  being  denuded 
of  its  covering,  characterized  by  evidencing  no  tend- 
ency to  heal.  The  term  "ulceration"  as  applied  to 
the  disorganization  of  tissue  and  granulating  wounds 
is  a  misnomer.  Strictly  speaking,  a  granulating 
surface  is  not  an  ulcer  and,  in  fact,  as  soon  as  a  true 
ulcer  commences  to  heal,  it  ceases  to  be  an  ulcer. 
Ulcers  occur  most  frequently  on  the  leg  and  are  in- 
variably the  result  of  interference  with  the  circula- 
tion, the  etiological  factors  being  varicose  veins, 
traumatism  or  constant  pressure.  Tubercular  and 
syphilitic  ulcers  are  but  ordinary  manifestations  of 
the  diseases  themselves  and  their  cure  depends  more 
upon  appropriate  systemic  treatment  than  upon 
local  measures. 

For  convenience,  a  varicose  ulcer  of  the  leg  will  be 
taken  as  an  example  of  the  usual  type  of  ulcer.  Such 
ulcers  are  frequently  encountered  in  hospital  and 
dispensary  practice  and,  because  they  so  tax  the 
physician's  ingenuity  and  skill,  are  generally  treated 
with  scant  courtesy  or  entirely  neglected.  To  no 
other  cause  can  the  average  physician's  indifference 
to  these  cases  be  ascribed.     The  usual  picture  pre- 


152.         MINOR  AND  EMERGENCY  SURGERY 

senting  is  a  large  sore,  of  irregular  outline,  with 
thick,  infiltrated  and  dusky  edges  and  an  indurated 
base,  which  is  often  covered  with  a  thin  white  layer 
of  tenaceous  necrotic  tissue.  Although  a  chronic 
condition,  an  ulcer  may  suffer  exacerbations  of  more 
or  less  acute  inflammation.  Should  it  become  puru- 
lent, suppuration,  sloughing  and  even  cellulitis  may 
follow. 

Treatment  of  Ulcers. — The  multiplicity  of  methods 
of  treatment  recommended  for  the  cure  of  indolent 
ulcers  by  various  writers  is  a  fair  indication  that  no 
single  one  always  proves  satisfactory  and  efficient. 
While  certain  well  defined  rules  may  be  formulated, 
the  surgeon  must  exercise  his  judgment  and  com- 
mon sense  in  each  case  to  obtain  universally  grati- 
fying results.  Each  step  in  the  treatment  should  be 
carried  out  with  a  definite  object  in  view  and  advance 
can  be  made  upon  the  previous  fiiTQ  foundation 
only : 

1.  Improve  the  local  circulation. 

2.  Cleanse  the  ulcer  and  surrounding  skin. 

3.  Subdue  inflammation. 

4.  Remove  necrotic  tissue  from  the  surface  of  the 
ulcer. 

5.  Promote  absorption  of  the  induration. 

6.  Stimulate  granulation. 

7.  Support  the  part  with  equalized  pressure. 

8.  Encourage  cicatrization. 

9.  Have  the  patient  w^ear  a  permanent  support. 

10.  Improve  the  patient's  general  condition. 

To  improve  the  circulation,  the  patient  should  be 
confined  to  bed  or  a  chair  and  the  leg  elevated.     Un- 


ULCERS— BED-SORES  153 

fortunately,  however,  it  is  rare  that  the  patient  will 
obey  these  instructions,  as  he  can  illy  afford  to  neg- 
lect his  occupation. 

If  all  surgeons  would  use  soap  and  water  with  the 
regularity  with  which  they  employ  antiseptics,  the 
latter  could  often  be  dispensed  with  and  healing 
would  occur  much  more  rapidly.  The  ulcer  and  sur- 
rounding skin  should  be  vigorously  scrubbed  with 
a  soft  brush  or  gauze  wipe.  After  drying  thoroughly, 
the  part  should  be  rubbed  with  alcohol  to  loosen 
scales  of  dried  discharge  and  devitalized  skin. 

If  inflammation  is  present,  it  can  be  reduced  by 
daily  applications  of  large  wet  dressings  of  Thiersch's 
solution  or  aluminum  acetate,  covered  with  a  firm 
gauze  bandage.  Asepsis  may  be  secured  by  paint- 
ing the  ulcer  with  tincture  of  iodine  at  each  dressing. 
The  gauze  must  be  kept  constantly  wet  until  the 
inflammation  is  subdued.  If,  however,  there  is  no 
evidence  of  inflammatory  reaction  and  the  ulcer  is 
dirty  and  foul,  it  should  be  cleaned  up  by  dressing 
with  balsam  of  Peru  for  a  few  days.  The  constant 
warm  bath  by  immersion  in  hot  saline  solution,  as 
described  in  -the  treatment  of  burns,  is  another  excel- 
lent method  of  treatment. 

The  necrotic  layer  often  observed  on  the  surface  of 
an  ulcer  is  most  easily  removed  by  dissecting  off  with 
thumb  forceps  and  scissors,  followed  by  delicate 
curettage. 

Absorption  of  the  indurated  tissues  at  the  base  and 
margins  of  the  ulcer  is  best  accomplished  by  criss- 
cross incisions,  carried  well  through  the  cicatricial 
tissues  at  the  base  and  edges.     Alternate  hot  and 


154  MINOR  AND  EMERGENCY  SURGERY 

cold  douches  and  massage  are  useful  adjuncts  to  the 
incisions. 

As  soon  as  the  inflammation  abates  and  the  ulcer 
presents  a  "clean"  appearance,  the  leg  should  again 
be  cleansed  with  soap  and  water  and  shaved  from 
ankle  to  knee.  The  ulcer  should  be  sprinkled  with 
a  generous  layer  of  powdered  naphthalin  crystals  to 
stimulate  granulation  and  then  covered  with  a  layer 
of  lint  spread  with  diachylon  ointment. 

These  applications  should  be  left  undisturbed  for 
about  ten  days,  meanwhile  exerting  constant  equal- 
ized pressure  over  the  whole  surface  of  the  part. 
This  is  best  done  by  strapping  from  ankle  to  knee, 
from  below  upward,  with  zinc  oxide  adhesive  plaster 
strips,  three-fourth  of  an  inch  wide  and  long  enough 
to  completely  encircle  the  leg  with  overlapping  of  the 
ends.  The  edges  of  each  strip  should  overlap  the 
preceding  one  (Fig.  20).  When  complete,  the  dress- 
ing should  be  covered  with  a  firm  bandage  or  an 
elastic  stocking.  To  remove  the  dressing,  saturate 
it  with  gasoline,  cut  from  below  upward,  and  strip 
off  in  one  sheet.  If  the  granulation  tissue  is  still 
some  distance  from  the  skin  surface,  another  similar 
dressing  may  be  applied  for  the  next  week.  As  soon 
as  the  granulations  approach  the  surface,  however, 
the  ulcer  should  be  irrigated  with  saline  solution  and 
Thiersch's  skin-grafts  spread  upon  its  surface.  Ex- 
uberant granulations  are  easily  removed  by  touching 
with  stick  silver  nitrate.  The  grafts  must  overlap 
each  other  and  the  skin  margins  and  should  be  covered 
with  several  layers  of  silver  leaf.  The  leg  is  re- 
strapped  for  two  or  three  weeks,  protecting  the  area 


ULCERS— BED-SORES 


^SS 


of  the  ulcer  by  smearing  the  superimposed  strips 
with  vaseline.  This  dressing  must  be  removed  very 
carefully  and  the  ulcer  will  then  be  found  to  be 
healed. 


Fig.  20. — Strapping  a  leg  ulcer. 

The  patient  should  be  instructed  to  wear  a  firm 
elastic  stocking  continuously,  protecting  the  delicate 
skin  by  wearing  a  white  silk  or  cotton  stocking 
underneath  the  elastic  one.     Johnson  recommends 


156  MINOR  AND  EMERGENCY  SURGERY 

sewing  four  or  five  ordinary  dress  stays  at  varying 
intervals  around  the  top  of  the  stocking  to  prevent 
rolling  downward,  if  the  stocking  is  one  that  reaches 
to  the  hip.  When  the  rubber  begins  to  stretch  from 
constant  use,  it  should  be  replaced  with  a  new 
stocking. 

Throughout  the  course  of  local  treatment  the 
patient's  general  condition  should  receive  careful 
attention.  The  emunctories  must  be  kept  active 
and  tonics  supplied  in  the  form  of  fresh  air  and  nutri- 
tious food.  Nux  vomica,  mercury,  arsenic  and 
potassium  iodide  may  be  administered  with  benefit. 

BED-SORES. 

Bed-sores  aie  localized  areas  of  gangrene  due  to 
the  circulatory  stasis  following  continued  pressure 
on  the  skin.  Their  production  is  favored  by  (i) 
the  continuous  pressure  exerted  by  the  stationary 
position  of  the  patient's  body,  (2)  arteriosclerosis, 
(3)  debility,  (4)  advanced  age,  (5)  imperfect  inner- 
vation and  (6)  the  presence  of  irritating  bodies  and 
secretions.  Bed-sores  most  often  occur  over  the 
sacrum  and  scapulae  and  are  particularly  common 
in  spinal  affections  and  wasting  diseases.  In  fracture 
cases,  the  long  continued  or  faulty  application  of 
splints  or  plaster-of-Paris  dressings  may  cause  pres- 
sure sores  which  are  identical  with  bed-sores. 

Competent  nursing  usually  prevents  the  develop- 
ment of  bed-sores  and  in  all  instances  in  which  the 
patient  is  confined  to  bed  for  any  length  of  time  the 
following  precautions  should  be  observed : 


ULCERS— BED-SORES  157 

1.  Change  the  position  of  the  patient  frequently, 
to  avoid  constant  pressure  on  any  one  region. 

2.  Bathe  the  entire  body  surface  daily  and  follow 
with  an  alcohol  sponge.  If  washing  with  soap  and 
water  is  impracticable,  the  patient  can  at  least  be 
sponged  with  alcohol. 

3.  Keep  the  bed  scrupulously  clean,  frequently 
brushing  the  sheets  free  of  cnimbs,  etc.,  and  keeping 
them  dry  and  smooth.  If  the  bedding  becomes  soiled 
with  perspiration,  urine  or  feces,  it  must  be  changed 
immediately. 

4.  The  water-bed  and  air  cushions  should  be  used 
in  suitable  cases  from  the  beginning.  It  is  not  neces- 
sary to  wait  for  areas  of  congestion  to  appear. 
Chamois  skin,  applied  with  its  softer  side  to  the 
area  of  skin  affected  or  threatened,  will  also  be 
found  useful  in  the  prevention  of  bed-sores. 

5.  The  areas  that  are  unavoidably  subjected  to 
pressure  and  which  cannot  be  comfortably  sup- 
ported with  a  circular  air  cushion  should  be  protected 
by  placing  cotton-wool  or  leather-backed  adhesive 
plaster  under  them. 

6.  Glycerite  of  tannin,  rubbed  in  twice  daily, 
will  harden  the  skin. 

If  the  parts  exposed  to  pressure  commence  to  show 
signs  of  congestion,  they  should  be  sponged  with  a  one 
in  eighty  solution  of  creosote  in  alcohol,  carefully 
dried  and  generously  dusted  with  zinc  oxide  powder. 
Applications  of  a  5  per  cent,  solution  of  silver  nitrate 
are  also  serviceable  at  this  stage.  When  the  skin 
has  broken  down  and  the  bed-sores  have  actually 
formed,  they  should  be  covered  with  a  moist  gauze 


158  MINOR  AND  EMERGENCY  SURGERY 

dressing  of  aluminum  acetate.  Each  day  when  the 
dressings  are  renewed,  the  visible  sloughs  should  be 
removed  and  the  surface  painted  with  a  2  per  cent, 
solution  of  silver  nitrate.  After  the  sloughs  have 
separated  and  healing  progresses,  the  dressings  should 
consist  of  balsam  of  Peru  or  boric  acid  ointment. 


CHAPTER  X. 
FOREIGN  BODIES. 

All  extraneous  material  entering  or  becoming 
embedded  in  the  tissues  must  be  considered  foreign 
matter.  Foreign  bodies  may  consist  of  practically 
any  substance  and  in  size  may  vary  from  infini- 
tesimal particles  to  large  masses.  The  presence  of 
foreign  bodies  in  the  tissues  is  an  item  of  importance, 
because  of  the  mischief  they  may  cause.  Excep- 
tionally, a  patient  may  be  unaware  of  the  entrance 
and  presence  of  a  foreign  body,  it  may  become 
encysted  and  remain  in  the  tissues  for  a  long  period 
without  arousing  his  suspicion.  Contrariwise,  foreign 
bodies  may  give  rise  to  (i)  irritation,  (2)  pressure, 
(3)  erosion,  (4)  infection,  (5)  sloughing,  (6)  secondary 
hemorrhage,  and  (7)  interference  with  healing,  usually 
in  the  order  mentioned.  As  a  rule,  the  longer  they 
are  left  undisturbed,  the  more  difficult  their  subse- 
quent extraction  or  removal  and  the  more  serious  the 
consequences.  Moreover,  foreign  bodies  have  a  ten- 
dency to  migrate,  because  muscular  contraction  and 
the  elasticity  of  the  tissues  push  them  on,  tmtil  after  a 
lapse  of  time  they  will  often  be  found  far  from  the 
original  point  of  entry.  It  is  therefore  obvious  that 
all  extraneous  material  should  be  removed  as  early 
as  possible. 

Foreign  bodies  must  be  accurately  located  prior 
to  any  attempt  at  removal.     Inspection,  palpation, 

*-59 


i6o  MINOR  AND  EMERGENCY  SURGERY 

gentle  sterile  probing  and  radiography  are  the  most 
reliable  methods  for  ascertaining  their  exact  situa- 
tion. It  must  be  remembered  that  a  single  x-vslj 
view  is  deceiving,  since  it  affords  no  information  as 
to  the  exact  depth  to  which  a  foreign  body  has  pene- 
trated. The  examination  should  include  both  an 
antero-posterior  and  lateral  view.  The  fiuoroscope 
may  be  employed  to  determine  whether  or  not  a 
foreign  body  moves  simultaneously  with  the  soft 
structures,  as,  for  example,  it  invariably  does  when 
embedded  in  a  tendon. 

To  remove  foreign  bodies,  the  most  efficient  means, 
in  order  of  their  advantage,  are:  (i)  irrigation, 
(2)  sponging,  (3)  the  use  of  forceps  and  curette 
(preceded  by  incision,  if  necessary),  and  (4)  magnet- 
ism. 

Foreign  Bodies  in  Subcutaneous  Tissues. — The 
majority  of  foreign  bodies  enter  the  subcutaneous 
tissues  through  an  open  wound  and  their  removal 
is  usually  a  simple  procedure,  except  in  punctured 
wotmds.  The  lattei  are  produced  by  sharp-pointed 
objects,  the  slightest  fragments  of  which,  if  remain- 
ing in  the  tissues,  may  cause  more  difficulty  in  re- 
moval than  the  appearance  of  the  wound  would 
indicate.  The  subsequent  contraction  of  the  skin 
aperture  or  even  its  union  per  primam  may  cause  the 
operator  much  annoyance. 

After  having  precisely  located  the  foreign  body, 
the  overlying  skin  is  anesthetized  and  incised.  The 
incision  should  be  sufficiently  extensive  to  permit 
thorough  search.  An  incision  that  is  too  small  is 
worse  than  useless,  since  blind  efforts  at  extraction 


FOREIGN  BODIES 


lOI 


only  result  in  pulling  up  shreds  of  tissue  and  may 
push  the  foreign  body  still  deeper  into  the  tissues. 
The  best  course  is  to  wait  until  the  object  becomes 
visible  before  attempting  its  removal.  It  should 
then  be  firmly  grasped  with  forceps  and  carefully 
withdrawn.  When  the  object  is  a  long,  slender, 
sharp-pointed  body,  Quain  recommends  that  an  inci- 
sion be  made  some  little  distance  from  the  foreign 
body,  so  that  it  may  be  grasped  with  forceps  at  right 
angles  to  its  longitudinal  axis  and  then  pushed  out 


Fig.  21. — ^Quain's  method  of  removing  a  deeply  embedded  foreign 
body  through  an  incision  at  the  point  of  entrance,  by  introducing  forceps 
through  a  second  incision. 

through  another  smaller  incision  at  the  point  of  en- 
trance (Fig.  2i).  If  a  foreign  body  is  embedded  be- 
neath a  nail  and  does  not  project  sufficiently  to  per- 
mit easy  extraction,  the  nail  may  be  painted  with 
liquor  potassas  and  the  softened  surface  scraped  off, 
until  the  remaining  nail  is  as  thin  as  paper.  It 
may  then  be  incised,  elevated  and  the  foreign  body 
removed. 

Foreign  bodies  in  the  eye  may  vary  from  a  small 


1 62  MINOR  AND  EMERGENCY  SURGERY 

particle  of  dust  to  a  splash  of  molten  metal  and  usu- 
ally lodge  in  the  conjunctiva  or  become  embedded  in 
the  cornea.  They  are  not  infrequently  associated 
with  burns,  particularly  if  the  offending  substance  is 
of  a  caustic  nature.  Although  immediate  removal 
is  imperative  in  all  these  cases,  when  foreign  bodies 
have  penetrated  to  some  portion  of  the  eye  other 
than  the  conjunctiva  and  cornea,  dislodgment  should 
be  attempted  by  those  solely  who  have  had  special 
ophthalmological  training.  Efforts  of  the  inexperi- 
enced to  remove  foreign  matter  from  the  deeper 
structures  of  the  eye  are  usually  futile  and  the  sight 
may  be  jeopardized  by  injudicious  treatment.  The 
nervous  sensibilities  and  structure  of  the  eye  are  so 
delicate  that  none  but  the  simplest  cases  should  be 
be  treated  by  the  general  surgeon.  Two  or  three 
minims  of  a  4  per  cent,  solution  of  cocaine  hydro- 
chlorate  dropped  into  the  eye  will  facilitate  inspec- 
tion and  removal  by  relieving  the  pain  and  spasm 
and  abolishing  the  reflexes.  The  lower  lid  should 
first  be  drawn  downward  and  the  patient  directed  to 
look  up.  This  exposes  the  conjunctival  folds  and 
the  surface  may  be  examined  by  oblique  illumination. 
The  surface  of  the  cornea  should  next  be  scrutinized 
through  a  magnifying  lens,  allowing  the  rays  of  light 
to  play  over  the  surface.  Lastly,  the  upper  lid  should 
be  everted  over  a  probe,  with  the  patient  looking 
downward,  and  the  tarsal  folds  carefully  inspected. 
As  soon  as  the  foreign  body  is  detected,  the  surface 
on  which  it  lies  should  be  brushed  with  a  little  cotton 
on  an  applicator,  dipped  in  boric  acid  solution.  If 
this  fails  to  remove  it,  the  foreign  body  being  deeply 


FOREIGN  BODIES  163 

embedded,  it  will  be  necessary  to  lift  it  out  gently 
with  a  sterile  spud.  Small  bits  of  metal  occasionally 
become  jammed  in  the  conjunctiva  or  sclera.  In 
these  cases  the  proximity  of  a  powerful  electric  mag- 
net is  usually  sufficient  to  remove  them.  Sometimes 
a  patient  will  complain  of  the  presence  of  a  foreign 
body  in  the  eye  when  none  can  be  detected.  This  is 
due  to  irritation,  which  often  persists  after  extrane- 
ous material  has  been  spontaneously  removed. 
Having  eliminated  the  foreign  material,  the  eye 
should  be  flushed  with  a  warm  boric  acid  solution  and 
soothed  with  a  drop  of  pure  castor  oil.  When  a 
chemical  bum  also  exists,  it  should  be  neutralized, 
sterile  olive  or  castor  oil  being  afterwards  dropped 
into  the  eye  and  cold  wet  compresses  applied. 

Foreign  bodies  in  the  external  auditory  canal  may 
consist  of  animate  or  inanimate  objects.  The  ani- 
mate objects  should  be  killed  by  dropping  a  little 
sweet  oil  in  the  ear,  after  which  they  may  be  removed 
by  syringing  copiously.  When  syringing,  the  stream 
should  be  directed  along  the  roof  of  the  canal,  so  that 
the  return  flow  will  be  as  forcible  as  possible.  Occa- 
sionally it  will  be  necessary  to  hook  behind  the  foreign 
body  with  a  wire  loop,  scoop,  or  a  hooked  probe,  but 
forceps  should  never  be  employed.  Foreign  bodies 
of  a  vegetable  nature  swell  when  immersed  in  water 
and  therefore  cannot  be  removed  in  the  ordinary 
way.  A  little  alcohol,  however,  dropped  into  the  ear 
and  permitted  to  remain  for  a  few  minutes  will  shrink 
them,  after  which  they  may  be  syringed  out  with 
more  alcohol.  Syringing  is  the  safest  method  of  re- 
m.oving  all  foreign  bodies  from  the  auditory  canal  and 


i64  ■       MINOR  AND  EMERGENCY  SURGERY 

should  be  continued  until  their  removal  is  effected. 
If  instinimentation  is  absolutely  necessary  (very  rare) , 
the  manipulations  should  be  deliberate  but  exceed- 
ingly gentle.  Meningitis  has  resulted  from  unskilled 
efforts  to  remove  foreign  bodies  from  the  ear. 

Foreign  bodies  in  the  nose  are  often  difficult  to 
detect,  because  they  may  remain  in  the  nose  for  some 
time  without  attracting  the  patient's  attention. 
A  discharge  resulting  from  inflammation  or  pres- 
sure necrosis  may  be  the  first  manifestation  of  the 
presence  of  a  foreign  body.  This  can  usually  be  lo- 
cated with  a  probe  and  may  be  removed  by  hook- 
ing behind  it  with  a  scoop  or  wire  loop.  Another 
efficient  method  of  removal  is  to  push  the  foreign 
body  back  to  the  pharynx.  When  this  is  done,  the 
patient's  head  must  hang  down,  to  prevent  the  dis- 
lodged foreign  body  dropping  into  the  larynx.  In 
struggling  children,  removal  is  often  attended  by 
dangers  from  traumatism  and  by  occasional  failure. 
An  ingenious  procedure  in  such  instances  is  to  hold  one 
hand  over  the  patient's  mouth  and  insert  one  end  of  a 
piece  of  rubber  tubing  snugly  into  the  free  nostril. 
The  other  end  of  the  tubing  is  held  in  the  mouth  of 
the  operator.  A  sudden,  vigorous  expiration  through 
the  tube  will  frequently  dislodge  the  foreign  body. 
Sometimes  it  is  necessary  to  narcotize  children  before 
attempting  removal. 

Foreign  Bodies  in  the  Pharynx,  Larynx  and  Tra- 
chea.— The  entrance  of  foreign  bodies  into  the  air 
passages  is  an  accident  of  frequent  occurrence  and 
usually  produces  symptoms  of  alarming  urgency. 
When  located  in  the  pharynx,  they  are  easily  removed 


FOREIGN  BODIES  165 

by  illuminating  the  region  in  which  they  lie  and 
extracting  with  curved  forceps.  The  ordinary  pro- 
bang  is  of  slight  value,  as  it  usually  scratches  and  ir- 
ritates the  mucous  membrane  without  removing  the 
object.  Induration  and  abscesses  are  not  rare  se- 
quelae in  these  cases,  hence  the  entire  surface  should 
be  closely  searched.  Foreign  bodies  may  become 
impacted  in  the  larynx  or  inspired  through  it  into 
the  trachea  and,  unless  promptly  removed,  dyspnea, 
cyanosis,  asphyxia  and  death  speedily  ensue.  A 
foreign  body  may  sometimes  be  felt  and  displaced  by 
thrusting  a  finger  down  the  throat.  If  this  is  not 
feasible,  an  opening  should  be  instantly  made  into 
the  cricothyroid  membrane.  Since  the  immediate 
admission  of  air  to  the  lungs  is  the  important  factor, 
rather  than  the  actual  removal  of  the  foreign  body 
itself,  laryngotomy  is  recommended  instead  of  trache- 
otomy, because  the  urgent  symptoms  are  usually 
found  in  the  cases  where  the  foreign  body  is  impacted 
in  the  glottis,  tracheotomy  requires  more  time,  and 
laryngotomy  is  the  safer  in  inexperienced  hands. 
Should  subsequent  tracheotomy  be  necessary  for 
extraction,  the  laryngotomy  offers  no  impediment 
to  its  perfomiance.  Artificial  respiration  is  fre- 
quently a  useful  adjunct  in  relieving  the  suffocation. 
Having  again  induced  respiration,  efforts  should 
be  made  to  ascertain  the  position  of  the  obstruction. 
Careful  laryngoscopic  examination  may  reveal  the 
location  of  the  foreign  body  and  it  may  then  be  re- 
moved with  laryngeal  forceps.  It  may  often  be  dis- 
lodged by  inverting  the  patient  and  slapping  him  on 
the  back.     This,  however,  is  a  dangerous  procedure, 


i66  •       MINOR  AND  EMERGENCY  SURGERY 

unless  laryngotomy  or  tracheotomy  has  been  per- 
formed, as  the  body  may  impact  in  the  vocal  cords 
and  again  suffocate  the  patient. 

Foreign  Bodies  in  the  Esophagus. — Large  masses 
of  food,  coins,  buttons,  false  teeth  and  pieces  of  bone 
may  be  swallowed  accidentally  and  lodge  in  the 
esophagus.  If  the  foreign  body  has  remained  for 
some  time,  it  may  cause  a  variety  of  symptoms: 
dysphagia,  pain,  tenderness,  reflex  cough,  eleva- 
tion of  temperature,  hemorrhage  or  emaciation. 
On  the  contrary,  it  may  produce  little  or  no  dis- 
comfort. The  dangers  of  permitting  a  foreign  body 
to  remain  in  the  esophagus  are :  (i)  pressure  necrosis, 
(2)  perforation,  (3)  peri-esophageal  abscess,  and  (4) 
starvation.  Occasionally  a  patient  will  swallow 
something  that  will  wound  the  esophagus  and  he  will 
experience  the  sensation  of  a  foreign  body  being 
present.  The  history  is  usually  indefinite  and  of 
little  diagnostic  value.  The  most  valuable  means 
of  determining  the  presence  or  absence  of  a  foreign 
body  is  an  x-vsiy  picture.  It  can  also  usually  be 
detected  by  passing  an  esophageal  bougie.  Unless 
promptly  removed,  the  prognosis  may  be  serious; 
death  may  occur  form  starvation,  sepsis  or  ulcera- 
tion into  the  aorta.  Foreign  bodies  generally  lodge 
behind  the  larynx  or  near  the  cardiac  orifice  of  the 
stomach,  these  being  the  points  at  which  the  lumen 
of  the  esophagus  is  narrowest. 

If  situated  high  up,  a  foreign  body  can  sometimes 
be  hooked  up  with  the  forefinger  or  removed,  through 
the  mouth,  with  forceps.  A  large  bolus  of  food, 
swallowed  quickly,  may  carry  it  into  the  stomach. 


FOREIGN  BODIES  167 

If  it  is  known  that  the  foreign  body  is  not  sharp, 
the  patient  may  be  caused  to  vomit  by  tickling  the 
back  of  the  throat  and  the  foreign  body  may  be 
projected.  This,  however,  is  a  dangerous  procedure 
if  the  object  is  sharp.  A  useful  device  is  the  ordinary 
horse-hair  probang,  which  is  introduced  closed, 
passed  beyond  the  foreign  body,  opened  and  with- 
drawn .  When  it  is  necessary  to  use  the  ' '  coin-catcher' ' 
or  long  curved  forceps,  the  instrument  employed 
must  be  manipulated  with  great  care.  It  is  prudent 
to  utilize  the  fluoroscope  when  attempting  instrumen- 
tal extraction,  as  perforation  of  the  esophagus  is  very 
easy  when  ulceration  already  exists  and  is  an  exceed- 
ingly dangerous  accident.  When  the  foreign  body  is 
located  near  the  cardiac  orifice,  it  can  occasionally 
be  pushed  into  the  stomach  with  the  blunt  end  of  a 
stomach  tube.  The  esophagoscope  is  a  valuable 
instrument  for  the  detection  and  extraction  of  a 
foreign  body.  When  used  for  this  purpose,  after 
cocainizing  the  pharynx,  it  should  be  introduced 
under  the  guidance  of  the  operator's  eye  and  without 
the  obturator.  As  soon  as  the  foreign  body  becomes 
visible,  it  is  seized  and  withdrawn  with  forceps. 
The  esophagoscope  is  a  dangerous  instrument, 
however,  in  inexperienced  hands,  as  the  slightest  in- 
accuracy may  cause  injury  of  the  mucous  membrane 
or  pref oration  of  an  area  of  ulceration.  A  cervical 
peri-esophageal  abscess  is  an  absolute  contra-indica- 
tion  to  the  use  of  the  esophagoscope.  If  all  other 
methods  fail,  an  esophagotomy  or  gastrotomy  must 
be  performed. 


CHAPTER  XI. 

SURGICAL  SHOCK  AND  COLLAPSE— DEATH. 

SURGICAL  SHOCK  AND  COLLAPSE. 

Surgical  shock  is  a  series  of  events  or  an  assem- 
blage of  phenomena  caused  by  injury,  characterized 
by  a  persistent  depression  of  arterial  tension,  due 
to  loss  of  vasotonic  or  vasomotor  activity,  thereby 
giving  rise  to  venous  stasis  in  the  large  internal 
veins,  with  a  subsequent  nervous  exhaustion  of  the 
cardiac  and  respiratory  centers  and  cerebral  anemia. 
In  other  words,  shock  is  a  symptom  complex,  the 
essential  phenomenon  of  which  is  reduced  blood 
pressure.  The  terms  shock,  collapse,  and  syncope 
are  often  confused  and  used  interchangeably.  In 
fact,  some  writers  maintain  that  collapse  is  merely 
a  mild  foiTn  of  shock.  The  latter,  however,  is  a 
simultaneous  suspension  of  function  rather  than  a 
true  exhaustion  of  all  the  nerve  centers  and  is  caused 
by  actual  loss  in  volume  of  the  blood  (hemorrhage) ; 
by  oxy-hemoglobin  starvation.  Synocope  (fainting) , 
on  the  other  hand,  is  but  a  temporary  cerebral 
anemia,  induced  by  a  momentary  hyperemia,  else 
where,  thus  disturbing  the  normal  blood  pressure 
equilibrium,  which  is  rapidly  and  spontaneously  re- 
stored. It  is  to  such  later  investigators  as  Crile, 
Gushing,  Wainwright  and  others  that  we  are  indebted 
for   experimental   work   on   shock  in  physiological 

i68 


SURGICAL  SHOCK  AND  COLLAPSE—DEATH  169 

laboratories  and  clinical  practice  and  every  student 
should  inform  himself  regarding  recent  research 
work  in  this  field,  on  which  studies  the  logical  con- 
sideration and  rational  treatment  of  shock  are  based. 
The  subject  is  one  of  such  magnitude  that  it  is 
obviously  beyond  the  confines  of  this  volume. 
In  shock,  all  vital  centers  suffer  primary  hyperten- 
sion but  the  vasomotor  center  soon  becomes  ex- 
hausted, lowering  the  blood  pressure,  with  exhaus- 
tion of  the  cardiac,  respiratory  and  other  centers, 
subsequently  causing  a  cerebral  anemia  due  to  loss 
in  circulatory  force.  In  collapse,  the  centers  are 
not  primarily  stimulated  but  directly  depressed  by 
the  actual  loss  of  blood,  and  all  centers  are  depressed 
simultaneously.  The  longer  the  hemorrhage  con- 
tinues the  longer  will  the  suspension  of  functions  exist. 
Consequently,  the  return  to  normal  depends  upon 
the  restoration  of  the  volume  of  blood. 

Causes   of  and  Factors  Predisposing   to  Surgical 
Shock  and  Collapse : 


Shock 


I .   Trau- 
matism 


1 


Opera- 
tions 


Accidental  injury. 

Rough  handling  of  tissues. 
Susceptibility      of      certain 
structures      (periosteum, 
peritoneum,  etc.) 
Exaggerated     nervous    im- 
pulses      (from      severing 
large  nerves,  etc.). 
Prolonged  operating. 
Burns  and  scalds. 
Psychic  disturbances  (fear). 
Excessive  anesthesia. 
Loss  of  vital  heat. 
Infantile,  diseased,  feeble  and  aged  subjects. 


lyx)  MINOR  AND  EMERGENCY  SURGERY 


Collapse 


TT  ,  f  Accidental. 

Hemorrhaee     <  t     .j     ^  , 
1  incidental. 

Sudden    withdrawal    of    large   quantities    of    fluid 

(ascites,  etc.). 


Manifestations    of    surgical    shock    and    collapse 

may  develop  suddenly  or  appear  gradually.  The 
symptoms  of  shock  are:  (i)  prostration,  (2)  pallor, 
(3)  pale  lips,  (4)  dull  and  staring  eyes  with  dilated 
pupils,  (5)  clammy,  moist  skin,  (6)  cold  extremities, 
(7)  frequent,  feeble  and  irregular  ("thready"  or 
imperceptible)  pulse,  (8)  marked  reduction  of  blood 
pressure,  (9)  feeble  respiration,  (10)  muscular 
relaxation,  (11)  subnormal  temperature,  and  (12) 
occasionally  relaxation  of  the  sphincters  of  the  blad- 
der and  rectum  and  (13)  nausea  and  vomiting.  The 
patient's  mentality  may  vary  from  perfect  retention 
of  the  senses  to  absolute  insensibility.  The  evi- 
dences of  collapse  are  essentially  those  of  shock 
with  three  notable  additions:  persistent  thirst, 
restlessness  and  air-hunger.  In  diagnosis,  the  history, 
nature  of  the  injury  and  a  blood  examination  should 
all  be  considered.  Oligocythemia  (a  red  cell  count 
of  3,500,000  or  less)  and  diminished  hemoglobin 
suggest  collapse  from  hemorrhage  rather  than  shock. 
Of  course,  it  is  not  unusual  to  observe  an  association 
of  both  shock  and  collapse  in  the  same  subject. 
Assuming  the  normal  blood  pressure  to  lie  between 
120  and  140  mm.  Hg.,  a  pressure  of  100  mm.  may 
be  considered  indicative  of  mild  shock,  at  or  below 
90  mm,  medium  and  at  or  below  70  mm.  profound 
shock.  The  concensus  of  opinion  seems  to  be  that 
if  profound  shock  once  becomes  firmly  established, 


SURGICAL  SHOCK  AND  COLLAPSE— DEATH  171 

it  is  irremediable.  In  these  cases  the  mechanical 
effect  of  appropriate  treatment  may  raise  the  blood 
pressure  temporarily  but  a  tine  reaction  is  not  ef- 
fected and  secondary  shock  invariably  follows.  An 
accurate  sphygmomanometer  is  an  indispensable  in- 
strument and  should  be  employed  in  all  cases  of 
shock  and  collapse. 

Prevention  of  Surgical  Shock  and  Collapse. — 
With  a  knowledge  of  the  predisposing  and  exciting 
causes  of  these  conditions,  it  is  obvious  that  much 
can  be  done  in  some  instances  to  prevent  or  limit 
their  development,  and  to  avoid  their  many  vicious 
sequels.  Unfortunately,  those  cases  resulting  from 
accidental  injury  are  beyond  the  surgeon's  control, 
hence  prophylactic  measures  can  be  applied  in  opera- 
tive cases  only.  These  will  consist  of:  (i)  prelimi- 
nary stimulation,  (2)  allaying  the  patient's  fears, 
(3)  a  preliminary  hypodermic  injection  of  morphine 
and  atropine,  (4)  maintaining  the  body  heat,  (5) 
perfect  technic,  (6)  avoiding  prolonged  exposure 
and  rough  handling  of  sensitive  tissues,  (7)  exact 
hemostasis,  (8)  operating  expeditiously,  and  (9) 
appropriate  after-treatment.  When  a  patient  ex- 
hibits evidence  of  beginning  shock  during  operation, 
it  is  more  prudent  to  stop  immediately  and  defer 
the  completion  of  the  operation  imtil  the  next  day 
than  to  proceed  and  "hope  against  hope  that  the  pa- 
tient will  not  die  cured."  Certain  structures  being 
particularly  sensitive  to  stimulation  and  tratmiatism, 
such  as  the  periosteiun  during  amputation,  etc.,  pre- 
liminary nerve  blocking  with  cocaine,  as  advocated 
by  Crile,  is  of  great  benefit.     This  may  be  obtained 


17-2  MINOR  AND  EMERGENCY  SURGERY 

either  by  spinal  analgesia  or  by  injections  directly 
into  the  nerve  sheaths.  The  cocaine  blocking 
lessens  the  blow  to  the  vasotonic  centers  and  dis- 
tributes the  violence  over  a  longer  period;  large 
nerves,  periosteum,  etc.,  may  then  be  severed  with 
impunity.  To  avoid  collapse  when  performing  a 
phlebotomy  or  paracentesis,  emptying  a  distended 
bladder,  etc.,  the  fluid  should  be  withdrawn  slowly 
and  the  entire  amoimt  should  never  be  removed  at 
one  sitting.  The  surgeon  is  often  confronted  with 
the  question  of  operating  during  shock  and  this 
point  is  still  the  subject  of  much  controversy.  In 
general,  sagacity  dictates  to  wait  until  reaction  has 
occurred,  unless  operation  is  imperative  to  save  life. 
Under  such  circumstances,  general  anesthesia  should 
be  avoided  as  often  as  possible.  If  the  operation  is 
deferred  until  reaction  occurs,  hemorrhage  must  be 
controlled  and  the  injured  area  protected  with  a 
wet  dressing.  All  cases  of  profuse  hemorrhage, 
primary  or  secondary,  internal  or  superficial,  and 
all  those  of  visceral  perforation  must  be  operated  upon 
immediately  regardless  of  shock,  else  death  from 
exsanguination  or  sepsis  is  certain. 

Treatment  of  Surgical  Shock  and  Collapse. — Since 
these  two  conditions  differ  physiologically,  their 
treatment  is  different.  The  cardinal  principle  of 
the  treatment  of  shock  is  to  establish  reaction  and 
stimulate  cardiac  action,  while  the  main  indication 
in  the  treatment  of  collapse  due  to  hemorrhage  is  to 
aid  in  the  restoration  of  the  blood  to  its  normal 
volume. 

The  reaction  from  shock  consists  of  permanent 


SURGICAL  SHOCK  AND  COLLAPSE— DEATH  i^^ 

elevation  of  the  depressed  blood  pressure,  evidence 
of  which  is  a  re-appearance  of  the  natural  color  and 
warmth  of  the  skin,  a  pulse  more  full  and  forcible, 
deeper  respirations  and  returning  sensibility  or  a 
quiet  sleep.  Some  writers  describle  a  condition  of 
excessive  reaction,  characterized  by  sudden  hyper- 
pyrexia and  coma  without  a  corresponding  improve- 
ment in  the  pulse  and  respiration,  which  they  as- 
cribe to  a  septic  intoxication.  It  is  more  usual  at 
the  present  time,  however,  to  observe  either  a  de- 
layed or  incomplete  reaction  or  no  reaction  at  all, 
when  the  patient  does  not  respond  to  remedial 
measure.  If  the  patient  is  in  great  pain  when  first 
examined,  he  should  receive  1/4  to  1/2  grain  of 
morphine,  be  put  to  bed  at  the  earliest  possible 
moment,  covered  with  warm  woolen  blankets,  being 
careful  not  to  impede  respiration,  and  surrounded 
with  hot  water  bottles  or  hot  bricks.  The  latter 
should  be  wrapped  in  cloths  to  prevent  contact  with 
the  body  surface,  because  prostrated  and  unconscious 
patients  are  especially  prone  to  burns  The  foot  of 
the  bed  should  be  elevated  to  lower  the  patient's 
head,  and  to  favor  a  return  of  blood  to  the  brain. 
The  exceptions  to  this  rule  are  cases  of  excessive  in- 
tracranial pressure.  In  these  cases,  even  though 
shock  exists,  Dawbarn,  Mayo  and  others  recommend 
a  partial  cerebral  anemia,  procured  by  sequestra- 
tion of  a  large  quantity  of  blood  in  the  extremities. 
The  latter  is  easily  obtained  by  cording  the  limbs  at 
their  proximal  extremities,  exerting  sufficient  pres- 
sure to  impede  the  venous  but  not  the  arterial  cur- 
rent nor  to  markedly  impair  heart  action.     Mani- 


174  MINOR  AND  EMERGENCY  SURGERY 

festly,  this  is  the  reverse  of  another  valuable  adjunct 
in  the  treatment  of  all  other  cases  of  shock ;  bandag- 
ing the  extremities  from  the  distal  end  toward  the 
trunk,  to  fortify  the  vital  centers  with  an  extra 
supply  of  blood.  Crile  has  elaborated  this  principle 
in  his  rubber  pneumatic  pressure  suit.  It  will  not  be 
amiss  to  repeat  that  while  these  measures  conduce  to 
safety  in  the  ordinary  cases  of  shock,  they  add  to  the 
danger  in  cases  of  intracranial  pressure.  Hot  normal 
saline  solution  should  be  used  early,  as  it  has  a  most 
excellent  effect  upon  unstriped  muscle  and  cerebral 
sympathetic  centers.  It  may  be  administered  by 
hypodermoclysis,  enteroclysis  or  intravenous  in- 
fusion. Both  Dawbarn  and  Kemp  have  shown  con- 
clusively that  the  customary  temperature  of  104°  F. 
is  too  low  and  that  the  best  and  most  permanent  re- 
sults upon  the  heart  and  blood-vessels  are  obtained 
when  the  saline  solution  is  given  at  116°  to  120°  F. 
About  two  quarts  should  be  cautiously  introduced; 
at  least  twenty  minutes  are  required  for  its  admin- 
istration, to  avoid  overwhelming  the  heart.  Hypo- 
dermoclysis or  enteroclysis  are  preferable  to  an 
intravenous  infusion,  because  the  flow  can  be  acceler- 
ated or  retarded  more  conveniently.  Adrenalin  chlor- 
ide (i-iooo)  acts  by  toning  up  the  unstriped  muscle 
of  the  blood-vessels  and  15  or  20  minims  may  be 
added  to  the  saline  solution.  Frequent  sphygmo- 
manometric  readings  should  be  taken  during  the 
introduction  of  the  solution  and  when  the  pressure 
rises  to  1 20  mm.  it  must  be  discontinued.  Twitch- 
ing of  the  limbs  heralds  the  development  of  convul- 
sions and  is  another  indication  for  stopping  the  ad- 


SURGICAL  SHOCK  AND  COLLAPSE—DEATH  175 

ministration  of  the  saline.  Should  the  pressure 
again  fall  perceptibly  and  the  pulse  become  weaker, 
the  adminstration  may  be  resumed.  For  this  pur- 
pose, Kemp's  rectal  tube  is  of  service.  A  permanent 
blood  pressure  of  100  mm.  and  a  pulse  rate  of  120 
may  be  considered  the  limit  of  safety.  Morphine, 
ammonia,  adrenalin  and  ergot  (ergotole)  are  the  most 
valuable  drugs  in  shock.  In  emergencies,  ammonia 
acts  as  a  harmless  stimulant  and  oft-times  contri- 
butes to  the  prevention  or  modification  of  shock. 
Morphine,  in  quarter-grain  doses,  is  useful  to  allay 
pain  and  quiet  the  patient  and  as  a  mild  circulatory 
stimulant.  The  latter  virtue  is  one  often  overlooked 
by  many  physicians.  Ergotole  and  adrenalin  chlo- 
ride ( I -1 000)  may  be  administered  in  saline  infusion 
or  hypodeniiatically  or  the  adrenalin  may  be  slowly 
dropped  into  the  nostrils.  The  administration  of  these 
preparations  must  be  frequently  repeated,  as  their 
effect  is  more  or  less  evanescent.  The  time-honored 
"stimulants,"  such  as  strychnine,  alcohol,  nitro- 
glycerine, etc.,  have  been  proven  to  be  physiologic 
fallacies  and  worse  than  useless.  They  cannot  stimu- 
late the  already  exhausted  nerve  centers,  which  are 
incapable  of  transmitting  normal  physiological  reflexes 
and  responding  to  stimulation,  nor  have  they  any 
effect  on  unstriped  muscle.  They  not  only  fail  to 
mitigate  shock  but  even  exaggerate  it  and  have  been 
entirely  abandoned  by  modem  surgeons.  If  res- 
piration flags,  artificial  respiration  may  be  insti- 
tuted. The  stomach  should  have  complete  rest,  all 
food  and  nauseous  medication  being  withheld  during 
shock  and  until  all  danger  is  past.     Strength  may  be 


176  MINOR  AND  EMERGENCY  SURGERY 

sustained  by  nutrient  enemata.     Hot  black  coffee, 
when  tolerated,  is  both  a  food  and  stimulant. 

The  main  indication  in  the  treatment  of  collapse 
due  to  hemorrhage  is  to  arrest  bleeding,  for  the  longer 
it  continues  the  more  prolonged  will  be  the  suspension 
of  functions.  When  hemorrhage  has  been  controlled, 
restoration  of  the  volume  of  blood  lost,  as  rapidly 
as  possible,  is  imperative.  Many  of  the  accessory 
measures  mentioned  in  the  treatment  of  shock  will 
also  prove  useful  in  collapse,  but  an  intravenous 
infusion  alone  is  practically  sufficient  to  raise  the 
blood  pressure  and  sustain  the  functions  of  the  cen- 
ters. In  other  words,  whereas  hot  saline  solution  is 
a  valuable  auxiliary  in  cases  of  shock,  it  is  an  ab- 
solute necessity  in  those  of  collapse ;  without  it  medi- 
cation is  useless.  Under  these  circumstances,  it  is 
desirable  to  introduce  the  saline  solution  more 
rapidly  than  in  shock,  hence  an  intravenous  infusion 
is  the  method  of  choice.  It  may  be  thrown  into  any 
large  vein  and,  although  one  of  the  superficial  veins 
of  the  forearm  is  usually  selected  for  convenience', 
the  internal  saphenous  vein  an3rwhere  above  the 
ankle,  as  suggested  by  Dawbam,  is  preferable,  be- 
cause there  are  no  adjacent  important  structures  and 
a  scar  on  the  leg  is  of  no  consequence.  The  patient 
should  be  confined  to  a  bed  with  its  foot  elevated, 
external  heat  applied  and  the  extremities  partially 
exsanguinated,  as  in  shock.  To  these  may  be  added 
an  increased  supply  of  oxygen,  which  may  be  pro- 
vided by  opening  windows  or  inhalations  of  pure 
oxygen  gas.  Direct  blood  transfusion  may  be  em- 
ployed when  a  donor,  the  necessary  facilities  and  in- 


SURGICAL  SHOCK  AND  COLLAPSE— DEATH  i^^ 

struments  are  at  hand.     The  drugs  used  in  the  treat- 
ment of  shock  are  also  serviceable  in  collapse. 

Collapse  occasionally  follows  sudden  withdrawal  of 
large  quantities  of  fluid ;  aspirating  ascites,  or  emptying 
a  distended  bladder.  This  accident  will  never  occur,  if 
technic  is  perfect  and  the  fluid  is  removed  gradually. 
A  large  quantity  of  fluid  must  be  removed  slowly  and 
the  entire  amount  never  withdrawn  at  one  time. 

DEATH. 

Many  phases  of  death  are  more  properly  included 
in  works  on  legal  medicine  and  medical  jurispru- 
dence and  therefore  the  care  of  the  moribimd  patient, 
the  determination  of  death  and  the  physician's  sub- 
sequent procedure  only  will  be  considered. 

Because  a  patient  is  apparently  dying  is  no  reason 
that  he  should  be  neglected.  It  is  well  to  bear  in 
mind  that  "while  there  is  life  there  is  hope"  and  an 
apparently  moribund  individual  has  been  known  to 
recover.  He  should  be  made  comfortable  and  his 
waning  vitality  conserved.  Cool,  smooth  bed- 
clothes that  do  not  restrict  or  interfere  with  respira- 
tion will  materially  add  to  his  comfort.  If  external 
heat  is  employed,  be  cautious  lest  the  sufferer  be 
burned.  Catheterization  and  warm  rectal  irriga- 
tions, as  often  as  required,  will  prevent  excessive 
intra-abdominal  pressure  and  resorption  of  noxious 
material.  Oxygen  should  be  liberally  supplied  to 
the  vitiated  atmosphere  by  opening  windows  and 
permitting  the  entrance  of  plenty  of  fresh  air  or  by 
inhalations  of  oxygen.  Lamps,  gas  flames  and  open 
fires  should  be  avoided,  if  practicable.     Such  medi- 


178  MINOR  AND  EMERGENCY  SURGERY 

cation  may  be  administered  as  circumstances  may 
demand.  Opiates  may  be  freely  used  if  the  patient 
is  restless  or  in  physical  pain.  The  attitude  of  the 
physician  should  be  one  of  cheerfulness  and  encour- 
agement and  not  indifference. 

When  circulation,  respiration  and  innervation  all 
cease,  the  patient  is  dead.  Cardiac  action  and  res- 
piration are  not  necessarily  arrested  simultaneously, 
m.omentary  absence  of  respiration  is  not  incompati- 
ble with  the  continuance  of  life,  and  instances  are 
recorded  in  which  one  or  the  other  has  apparently 
ceased  and  yet  the  patient  recovered.  This,  how- 
ever, is  open  to  question.  It  is  more  logical  to  as- 
sume that  either  the  heart's  action  was  so  extremely 
feeble  or  the  respiratory  movements  so  shallow  that 
one  or  the  other  was  imperceptible,  even  with  the 
stethoscope.  Death  is  usually  verified  by  the  ces- 
sation of  circulation  and  respiration,  corroborated 
by  a  stethoscopic  examination.  In  view  of  the 
possibility  of  error  in  mistaking  suspended  animation, 
lethargy,  catalepsy,  etc.,  for  actual  death,  the  above 
examination  cannot  be  accepted  as  adequate.  The 
unmistakable  signs  of  death,  upon  which  a  positive 
determination  may  be  based  are:  (i)  complete  arrest 
of  cardiac  action,  (2)  complete  arrest  of  respiration, 
(3)  primary  period  of  muscular  relaxation,  preceding 
rigor  mortis,  (4)  abolition  of  reflexes,  (5)  intense 
pallor  or  discoloration  of  the  skin  and  mucous  mem- 
branes, (6)  eyes  partly  open  and  fixed,  (7)  flaccidity 
and  softening  of  the  eye-ball,  (8)  absence  of  pupil- 
lary reaction,  (9)  gradual  opacity  of  the  cornea,  and 
(10)  rapid  reduction  of  body  temperature. 


SURGICAL  SHOCK  AND  COLLAPSE— DEATH  179 

Death  having  ensued,  it  is  the  physician's  duty  to 
thoroughly  examine  the  body  and  confirm  the  oc- 
currence by  unquestionable  evidence.  The  law  re- 
garding the  physician's  subsequent  procedure,  in 
deaths  due  to  other  than  natural  causes,  varies  in 
the  different  States  and  Counties,  but,  in  general,  a 
death  certificate  should  not  be  furnished  without  the 
authority  of  the  proper  official.  When  the  ambu- 
lance surgeon  is  called  upon  to  verify  a  sudden  death, 
he  should  note  carefully  the  circtmistances  and  facts 
but  should  leave  the  body  undisturbed.  This  will 
avoid  confusion  and  obscurity  of  certain  details  upon 
later  investigation  by  the  municipal  authorities.  If, 
however,  the  physician  is  empowered  and  directed  to 
sign  the  death  certificate  in  doubtful  cases,  he  should 
clearly  state  the  means  or  instrument  of  death,  as 
well  as  the  immediate  cause.  The  certificate  should 
also  state  whether  the  death  was  due  to  accident, 
suicide  or  homicide. 


CHAPTER  XII. 

MINOR  OPERATIONS 
ARTIFICIAL  RESPIRATION. 

Indications. — Asphyxia  and  suspended  animation : 
(i)  inhalation  of  noxious  gases,  (2)  drug  toxemias, 
(3)  submersion,  (4)  strangulation  and  (5)  electric 
shocks. 

Contraindications. — The  patient  being  in  an  at- 
mosphere of  vitiated  air  or  that  contaminated  with 
noxious  gases. 

Sylvester's  Method. — i.  Place  the  patient  in  a 
supine  position,  with  the  head  well  extended  by  a 
folded  blanket  imder  the  shoulders  (Fig.  22). 

2.  Stand  at  the  patient's  head  and  grasp  the  fore- 
arms near  the  elbows. 

3.  For  inspiration,  draw  the  arms  steadily  and 
gently  well  above  the  head. 

4.  Keep  the  arms  stretched  upward  for  two  seconds, 

5.  For  expiration,  turn  down  the  arms,  place  them 
by  the  sides  and  gently  compress  the  thorax  for  two 
seconds. 

6.  Repeat  these  movements  about  fifteen  times 
to  the  minute. 

Schafer's  Method. — i.  Have  the  patient  lie  prone, 
with  the  face  turned  to  one  side. 

2.  Exert  imiform  pressure  on  the  lower  ribs  and 
loins. 

180 


MINOR  OPERATIONS  i8i 

3.  Remove  the  pressure  to  allow  inspiration. 

4.  Repeat  these  procedures  fifteen  times  a  minute. 
Laborde's  Method. — i.  Grasp  the  tongue  deeply 

and  firmly  with  a  layer  of  gauze  or  a  flat  bladed 
tongue  forceps. 


Fig.  22. — a.  Correct  and  b  incorrect  positions  of  patient  for  artificial 
respiration. 


2.  Draw  the  tongue  forward  forcibly  and  suddenly. 

3.  Relax  the  tongue  quickly  and  completely. 

4.  Repeat  this  intermittent  traction  every  four 
seconds. 


i82  IMINOR  AND  EMERGENCY  SURGERY 

Faradization. — i.  Press  one  electrode  on  the  right 
side  of  the  neck  over  the  right  phrenic  nerve. 

2.  Apply  the  other  electrode  over  the  lower  ribs  on 
the  right  side  (Fig.  23).  The  left  side  is  avoided  in 
order  not  to  interfere  with  cardiac  action. 

3.  A  weak  faradic  current  is  turned  on  during  in- 


FiG.  23. — Electrodes  applied  properly  to  induce  inspiration. 

spiration  and  turned  off  as  soon  as  expiration  com- 
mences. 

Precautions. — (i)  Correct  diagnosis  is  important ; 
(2)  the  upper  respiratory  tract  must  be  freed  from 
obstruction;  (3)  if  the  air  is  contaminated,  pure  air 
must  be  obtained;  (4)  impediments  to  free  respira- 
tory movements  must  be  removed;  (5)  external  heat 


MINOR  OPERATIONS  183 

and  friction  should  be  applied  early ;  (6)  all  manipu- 
lations must  be  deliberately  and  regularly  performed, 
(7)  artificial  respiration,  when  indicated,  should 
always  be  continued  for  at  least  half  an  hour  and 
persevered  in  much  longer,  if  there  is  the  slightest 
indication  of  life;  (8)  a  combination  of  the  various 
methods  of  artificial  respiration  will  often  prove  ad- 
vantageous; (9)  inhalations  of  oxygen  gas,  blood- 
letting and  suitable  cardiac  and  respiratory  stimu- 
lants are  useful  adjuncts. 

LARYNGOTOMY. 

Indications. — (i)  Sudden  obstruction  of  the  larynx; 
(2)  therapeutic  purposes;  (3)  as  a  preliminary  pre- 
ventive measure  to  some  surgical  operations. 

Contraindications. — (i)  Obstructions  below  the 
larynx;  (2)  age  tmder  thirteen  years,  as  the  crico- 
thyroid space  is  too  narrow. 

Technic. — i.  Extend  the  patient's  neck  strongly. 

2.  Procure  local  or  general  anesthesia. 

3.  Steady  the  larynx  with  the  thumb  and  fingers 
of  the  left  hand. 

4.  Make  an  incision  from  the  center  of  the  thyroid 
cartilage,  extending  downward  an  inch  and  a  half. 

5.  Avoid  or  ligate  and  divide  the  cricothyroid 
artery. 

6.  Pltmge  a  knife  transversely  through  the  crico- 
thyroid membrane  exactly  in  the  median  line,  to  the 
depth  of  half  an  inch  (Fig.  24). 

7.  Causes  the  opening  to  gape  by  everting  the  lips, 
until  a  tube  can  be  procured. 

8 .  ExecLite  the  necessary  intralaryngeal  procedures. 


1 84  -        MINOR  AND  EMERGENCY  SURGERY 

9.  Insert  a  laryngeal  tube  with  the  end  directed 
downward. 

10.  If  an  obstruction  is  promptly  and  perma- 
nently removed,  the  cannula  may  be  omitted  and  the 
wound  closed  with  fine  sutures. 

11.  Apply  a  small  square  of  lint  smeared  with  an 


Fig.  24. — Laiyngotomy  through  the  cricothyroid  membrane. 


emollient  to  prevent  irritation  of  the  wound. 

Precautions. — (i)  Fix  the  larynx  firmly  to  pre- 
vent slipping  from  under  the  point  of  the  knife;  (2) 
hold  the  knife  so  that  not  more  than  half  an  inch 
projects  beyond  the  fingers  and  thumbs;  otherwise 
the  larynx  may  be  accidentally  transfixed;  (3)  don't 
mistake  the  hyoid  bone  for  the  cricoid  cartilage. 


MINOR  OPERATIONS 


185 


TRACHEOTOMY. 

Indications. — (i)  Sudden  obstruction  of  the  tra- 
chea; (2)  therapeutic  purposes;  (3)  as  a  preliminary- 
preventive  measure  to  certain  surgical  operations; 
(4)  whether  the  trachea  is  opened  above  (high  opera- 
tion) or  below  (low  operation)  the  isthmus  of  the 


Fig.  25. — High  and  low  tracheotomy  incisions. 


thyroid  body  will  depend  upon  the  anatomical  pe- 
culiarities and  the  existing  circinnstances  in  each 
case  (Fig.  25). 

Contraindications. — (i)  Extreme  urgency  (lar^^n- 
gotomy  preferable) ;  (2)  high  operation  is  contra- 
indicated  in   laryngeal  diseases,  because  the  prox- 


1 86  MINOR  AND  EMERGENCY  SURGERY 

imity  of  the  tracheotomy  cannula  may  irritate  and 
exaggerate  the  trouble. 

Technic. — i.  Extend  the  neck  strongly, 

2.  Anesthetize  the  local  parts. 

3 .  Make  a  free  incision  in  the  skin  according  to  the 
location  of  the  proposed  tracheal  incision,  exactly 
in  the  median  line. 

4.  Dissect  by  blunt  dissection  down  to  the  trachea 
rapidly  but  carefully. 

5.  Have  an  assistant  hold  the  soft  structures  to 
each  side  with  blunt  hooks. 

6.  Control  hemorrhage. 

7.  Avoid  the  isthmus  of  the  thyroid  gland  by 
pushing  it  up  or  down,  as  may  be  practicable. 

8.  Draw  up  and  steady  the  trachea  by  fixing  a 
tenaculiim  in  its  upper  part. 

9.  Thrust  the  knife,  with  its  back  downward,  into 
the  trachea  three  or  four  rings  below  the  tenaculum 
and  cut  upward. 

10.  Dilate  the  aperture  laterally  with  the  handle 
01  the  scalpel. 

11.  Insert  a  tracheotomy  tube  of  appropriate  size. 

12.  Secure  the  tube  with  a  tape  carried  twice 
around  the  neck. 

13.  Keep  the  tube  clear  at  all  times  and  prevent 
access  of  cold  dry  air  by  keeping  flannel,  wrung  out 
in  hot  water,  over  the  opening  of  the  tube. 

Precautions. — (i)  Don't  let  an  over-zealous  as- 
sistant draw  the  head  so  far  back  as  to  Suffocate 
the  patient  before  operation  is  begun ;  (2)  see  that  all 
necessary  instruments  are  at  hand;  (3)  make  all  in- 
cisions exactly  in  the  median  line  and  sufficiently 


MINOR  OPERATIONS  187 

long  to  secure  good  exposure;  (4)  don't  open  the 
trachea  until  all  arterial  hemorrhage  has  been  con- 
trolled; (5)  be  careful  not  to  transfix  the  trachea  or 
wound  the  esophagus  when  incising  the  trachea; 
(6)  tracheotomy  is  a  difficult  and  dangerous  operation 
in  inexperienced  hands. 

HYPODERMIC  INJECTIONS. 

Indications. — To  secure  rapid,  thorough  and  cer- 
tain absorption  of  medicaments,  especially  stimu- 
lants, sedatives  and  emetics. 

Contraindications. — (i)  Irritant  substances;  (2) 
insoluble  substances;  (3)  substances  ineffective  in 
small  dose;  (4)  when  it  is  necessary  for  the  patient 
or  some  other  inexperienced  person  to  administer 
the   medication. 

Technic. — i.  With  the  needle  detached,  draw  in  a 
syringe  full  of  water. 

2.  Empty  the  syringe  into  a  teaspoon  or  similar 
article  and  boil  the  water  over  a  gas  flame  or  burning 
match. 

3.  Dissolve  the  tablet  in  the  boiled  water. 

4.  Aspirate  the  resulting  solution  into  the  syringe. 

5.  Screw  the  needle  on  firmly. 

6.  Point  the  needle  directly  upward  and  expel  a 
few  drops  by  gentle  pressure  on  the  piston  to  make 
sure  that  the  needle  and  syringe  are  free  from  air. 

7 .  Clean  a  small  area  of  skin  with  cotton  moistened 
with  alcohol. 

8.  Dry  with  cotton. 

9.  Pinch  up  the  skin  with  the  fingers  and  thumb  of 


i88 


MINOR  AND  EMERGENCY  SURGERY 


the  left  hand  so  that  the  fold  is  parallel  to  the  course 
of  the  neighboring  blood-vessels. 

lo.  Plunge  the  needle  quickly  into  the  subcuta- 
neous areolar  tissue,  with  the  point  directed  to- 
ward the  body,  being  careful  to  avoid  blood-vessels 


Fig.  26. — a,  Hypodermic  needle  introduced  correctly;    h,  hypodermic 
needle  introduced  incorrectly. 

(Fig.  26). 

11.  Inject  the  contents  of  the  syringe  slowly  by 
exerting  uniform  pressure  on  the  piston. 

12.  Withdraw  the  needle  slowly  and  massage  the 
small  tumefaction  gently  toward  the  tinink. 


MINOR  OPERATIONS  189 

13.  Seal  the  point  of  entrance  with  collodion. 

Precautions. — (i)  Select  a  syringe  of  uniform  cali- 
ber with  a  properly  fitting  piston;  (2)  see  that  the 
washers  are  in  good  condition  and  that  the  joints  do 
not  leak;  (3)  the  needle  must  be  sharp  and  pervious; 

(4)  keep  a  fine  wire  in  the  needle  when  not  in  use ; 

(5)  the  solution  injected  must  be  perfect,  sterile  and 
warm,  therefore  solutions  must  always  be  freshly 
prepared;  (6)  strong  acid  and  alkaline  solutions  are 
unfitted  for  hypodermic  administration,  because  they 
cause  severe  local  irritation ;  (7)  be  sure  of  an  accurate 
dose  and  avoid  hypermedication ;  (8)  don't  boil 
the  solution  after  dissolving  the  medicament,  as 
many  substances  are  decomposed  by  a  temperature 
of  212°  F. 

Dangers. — From  faulty  technic  are:  (i)  needle 
abscess,  from  a  non-sterile  needle;  (2)  injecting  the 
medicament  into  a  vein ;  (3)  introduction  of  air  into  a 
vein ;  (4)  subsequent  formation  of  drug  habits  by  the 
patient  (insignificant  in  emergency  cases) . 

SKIN-INFILTRATION  ANESTHESIA. 

Indications. — To  secure  local  anesthesia,  or  local 
analgesia:  (i)  to  minimize  or  prevent  pain  in  trivial 
operations ;  (2)  to  avoid  or  limit  the  necessity  for  the 
employment  of  general  anesthesia  in  major  opera- 
tions. 

Contraindications. — (i)  Inflammation  or  its  prod- 
ucts existing  in  the  tissues  subjacent  to  the  region 
to  be  anesthetized,  because  the  additional  stretching 
incident  to  the  infiltration  of  the  already  tense  skin 
is  extremely  painful;   (2)  very  yoimg  and  nervous 


196 


MINOR  AND  EMERGENCY  SURGERY 


patients;  (3)  regions  in  which  the  resulting  edema 
obhterates  the  dividing  line  between  diseased  and 
healthy  tissue. 

Technic. — i.  Observe  all  aseptic  and  antiseptic 
precautions,  as  in  hypodermic  injections. 

2.  Fill  a  hypodermic  syringe  with  a  i  per  cent, 
solution  of  ^  eucaine  or  cocaine  hydrochlorate, 
adding  a  minim  or  two  of  adrenalin  chloride. 


Fig.  27. — a,  Correct  and  b   incorrect    method    of    inserting  needle  for 
skin  infiltration  anesthesia. 


3.  Cleanse  the  skin  with  alcohol. 

4.  Insert  the  needle  into  the  meshes  of  the  skin 
itself  and  not  into  the  subcutaneous  areolar  tissue 
(Fig.  27). 

5.  Inject  the  solution  parallel  to  the  surface,  until 
a  good  sized  wheal  is  formed. 

6.  If  the  first  wheal  does  not  cover  a  sufficient  area. 


MINOR  OPERATIONS  191 

the  needle  should  be  re-inserted  in  its  margin  and  an 
adjoining  one  injected. 

7.  After  waiting  a  few  seconds,  the  skin  may  be 
freely  incised. 

Precautions. — (i)  Solutions  of  cocaine  stronger 
than  2  per  cent,  are  unnecessary  and  dangerous; 
(2)  the  addition  of  adrenalin  chloride  has  a  salutory 
effect  upon  the  action  of  the  anesthetic  (tends  to  favor 
hemostasis  and  prevent  a  cocaine  toxemia) ;  (3) 
boiling  decomposes  cocaine  solutions ;  (4)  more  than 
one-third  of  a  grain  in  all  should  never  be  used;  (5) 
the  duration  of  the  analgesia  is  increased  with  an  in- 
crease in  strength  of  the  solution ;  (6)  whenever  pos- 
sible, partial  anemia  of  the  part  should  be  procured, 
as  this  favors  diffusion  of  the  zone  anesthetized; 
when  using  cocaine  anesthesia  on  a  limb,  moderate 
constriction  above  the  point  of  injection,  by  retard- 
ing venous  return,  confines  the  anesthetic  locally 
diminishes  general  absorption  and  possible  tox- 
emia; (7)  a  very  fine  and  sharp  needle  will  not  cause 
pain  when  inserted. 

ETHYL  CHLORIDE  ANESTHESIA. 

Indications. — To  secure  anesthesia  of  a  restricted 
area,  particularly  adapted  to  inflammatory  tissue. 

Contraindications. — Cases  in  which  deep  pene- 
tration and  dissection  of  tissue  are  required,  or  in 
which  prolonged  local  anesthesia  is  necessary. 

Technic. — i .  Cleanse  the  skin  with  soap  and  water 
and  alcohol. 

2.  Grasp  the  container  with  the  whole  hand. 


192, 


MINOR  AND  EMERGENCY  SURGERY 


3.  Loosen  the  valve  sufficiently  to  permit  a  fine 
spray  being  projected. 

4.  Direct  the  spray  upon  the  skin,  holding  the  con- 
tainer some  3  or  4  inches  away  (Fig.  28). 

5.  Stop  the  spray  as   soon   as  the  skin  area  is 
thoroughly  whitened. 

6.  Wait  until  the  whitening  has  nearly  disappeared 
before  incising. 

Precautions. — (i)   Be  sure  that  the  nozzle  of  the 


Fig.  28. — a,  Correct  and  b  incorrect  method  of  obtaining  ethyl  chloride 
anesthesia. 

container  does  not  leak;  (2)  keep  a  firm  grasp  on  the 
container,  because  it  is  the  heat  from  the  hand  that 
exerts  pressure  within  the  tube  and  causes  vapori- 
zation; (3)  maintain  a  fine  spray  but  avoid  a  stream; 
(4)  too  prolonged  freezing  will  be  followed  by  devi- 
talization and  sloughing;  (5)  the  slight  discomfort 
due  to  reaction,  experienced  by  the  patient  after- 
wards, is  of  no  consequence. 


MINOR  OPERATIONS  193 


ASPIRATION. 


"Aspiration"  refers  to  a  method  of  withdrawing 
fluids  from  a  cavity  by  suction,  in  contradistinction 
to  "paracentesis,"  which  refers  to  simple  puncture  of 
the  walls  of  a  cavity.  For  aspiration  an  exhausting 
syringe  or  apparatus  (aspirator)  is  required,  whereas 
for  paracentesis  internal  pressure  and  gravitation 
only  are  depended  upon  for  removal  of  the  fluid 
through  a  trocar  or  an  incision. 

Indications. — (i)  Diagnostic  confirmation ;  (2)  evac- 
uation of  collections  of  serum,  blood  or  pus  from  a 
cavity;  (3)  as  an  emergency  operation  in  severe  cases 
of  retention  of  urine  in  which  efforts  at  catheteri- 
zation have  failed ;  (4)  spina  bifida. 

Contraindications. — (i)  Extensive  pyemic  ab- 
scesses; (2)  when  the  density  of  pus  is  so  great  that 
it  will  not  flow  through  the  needle ;  (3)  when  sloughing 
is  extensive  and  the  shreds  continually  plug  the 
needle ;  (4)  when  large  blood-vessels  or  other  impor- 
tant structures  that  cannot  be  avoided  are  interposed 
between  the  surface  and  the  collection  of  fluid. 

Technic. — i .  Observe  all  aseptic  and  antiseptic  pre- 
cautions and  cleanse  the  overlying  skin  or  mucous 
membrane. 

2.  Press  down  a  small  area  of  skin  slightly  above 
the  site  of  the  proposed  perforation,  so  that  when 
released  by  withdrawal  of  the  needle  the  aperture  in 
the  skin  will  lie  above  that  through  the  underlying 
structures,  thus  avoiding  subsequent  leakage. 

3.  Anesthetize  the  skin  with  ethyl  chloride. 
13 


194  MINOR  AND  EMERGENCY  SURGERY 

4.  Insert  a  suitable  needle,  firmly  but  gradually, 
until  the  point  is  felt  to  be  free  in  the  cavity. 

5.  Attach  a  syringe  with  the  piston  depressed  or 
the  tube  of  an  aspirating  apparatus  (preferably 
Potain's  aspirator)  in  the  receiving  bottle  of  which  a 
vacuum  has  been  previously  created  by  means  of  an 
attached  pump. 

6.  If  a  syringe  is  employed,  withdraw  the  piston 
slowly. 

7.  If  a  Potain  apparatus  is  used,  open  the  vent 
leading  into  the  receiving  bottle. 

8.  If  the  limien  of  the  needle  becomes  obstructed 
during  the  out-flow  of  fluid,  it  may  be  cleared  by 
changing  its  direction,  by  reversing  the  action  of  the 
syringe  temporarily  or  by  removing  it,  clearing  it 
and  introducing  it  elsewhere. 

9.  When  the  flow  ceases,  the  exhausting  pimip 
may  be  operated  or  the  needle  slightly  withdrawn. 

10.  When  the  greater  part  of  the  fluid  is  evacuated, 
the  needle  should  be  removed  and  the  perforation 
sealed  with  a  little  cotton  painted  with  collodion. 

1 1 .  Exert  firm  pressure  on  the  part  with  a  suitable 
dressing  to  support  the  walls  of  the  cavity  and  aid  in 
preventing  a  return  of  the  affection. 

Precautions. — (i)  Always  test  the  aspirator  before 
using;  (2)  be  sure  that  the  receiving  bottle  contains 
a  vacuiun  and  not  compressed  air;  (3)  the  diameter 
of  the  needle  selected  will  depend  upon  the  quantity 
and  viscosity  of  the  fluid  to  be  evacuated  through  it ; 
it  should  be  reasonably  small;  (4)  the  site  at  which 
the  needle  is  introduced  should  obviously  be  at  the 
lowest  accessible  point  to  which  the  fluid  extends; 


MINOR  OPERATIONS 


195 


(5)  introduce  the  needle  slowly,  so  that  it  will  not 
pass  entirely  through  the  cavity  and  reach  the  oppo- 
site wall  or  wound  deeper  structures  unnecessarily 
before  the  fluid  has  an  opportunity  to  escape;  (6) 
never  remove  the  whole  of  a  large  collection  of  fluid 
at  one  time;  (7)  re-accumulations  are  common  after 
aspiration  and  repetition  is  often  necessary. 

PARACENTESIS  ABDOMINIS. 

Indications. — To  evacuate  fluid  from  the  abdom- 
inal cavity. 

Contraindications. — A  distended  bladder. 
Technic. — i.  Shave  and  cleanse  the  skin. 

2.  Have  the  patient  sit  in  a  chair  or  lie  on  his 
side  on  the  edge  of  the  bed. 

3.  Support  the  abdominal  wall  by  placing  a  wide 
bandage  or  towel  with  a  central  opening  around  the 
patient  and  have  an  assistant  exert  firm  pressure 
from  behind. 

4.  Draw  down  the  skin  immediately  above  the 
point  to  be  punctured. 

5.  Cocainize  the  area  of  puncture. 

6.  Make  a  small  preliminary  skin  incision  in  the 
linea  alba. 

7.  Insert  a  small  straight  cannula  and  trocar, 
carefully  but  quickly  (Fig.  29). 

8.  Withdraw  the  trocar,  leaving  the  cannula  in 
situ  and  have  an  assistant  tighten  the  abdominal 
supporter  as  the  fluid  is  evacuated  and  the  enlarge- 
ment decreases. 

9.  If  the  cannula  becomes  obstructed,  it  may  be 
cleared  by  passing  a  probe  through  it. 


196 


MINOR  AND  EMERGENCY  SURGERY 


10.  If  the  fluid  flows  too  freely,  it  may  be  retarded 
by  a  compress  over  the  outer  opening. 

11.  Withdraw  the  cannula  and  seal  the  opening 
with  cotton  and  collodion. 

Precautions. — (i)  Empty  the  bladder  and  bowels; 
mistaking  a  distended  bladder  for  other  collections 
of  fluid  is  an  inexcusable  error;  (2)  verify  the  area 
of  dulness  by  percussion  immediately  before  para- 


FiG.  29. — Correct  position  for  paracentesis  abdominis. 

centesis;  (3)  sudden  or  complete  removal  of  the  fluid 
may  precipitate  collapse ;  (4)  in  general,  the  precau- 
tions for  aspiration  obtain  for  paracentesis. 

LUMBAR  PUNCTURE. 

Indications. — (i)  To  withdraw  cerebro-spinal  fluid 
to  make  or  verify  a  diagnosis  or  relieve  excessive 
pressure  within  the  vertebral  canal;  (2)  to  introduce 


MINOR  OPERATIONS  197 

antitetanic  serum  or  other  therapeutic  agents  into 
the  cerebro-spinal  axis. 

Technic. — i.  Administer  a  preliminary  dose  of 
morphine  and  atropine,  unless  distinctly  contra- 
indicated  by  the  patient's  general  condition. 

2.  Have  the  patient  lie  on  his  side  on  the  edge  of 
the  bed,  with  the  body  cuived  forward,  or  have 
him  sit  up  in  the  same  position. 

3.  Identify  the  twelfth  dorsal  vertebra  by  means 
of  the  last  rib  and  count  downward  to  the  spine  of 
the  fourth  lumbar  vertebra.  Deep  palpation  is 
necessary. 

4.  Select  a  point  half  an  inch  to  the  side  of  the 
median  line  and  freeze  it  with  ethyl  chloride. 

5.  Incise  the  skin  at  this  point. 

6.  Select  a  slender  needle  4  inches  long,  the  stylet 
of  which  is  ground  flush  with  the  end  of  the  needle 
itself  (Dawbarn's  needle). 

7.  Pass  the  needle  through  the  subcutaneous  tis- 
sues obliquely  upward  and  inward  with  the  stylet  in 
place. 

8.  A  sense  of  diminished  resistance  indicates 
penetration  of  the  canal. 

9.  Withdraw  the  stylet;  the  issuance  of  a  few 
drops  of  cerebro-spinal  fluid  will  follow. 

10.  Catch  the  fluid  in  a  test-tube  or  other  suitable 
container. 

11.  Withdraw  the  needle  slowly  and  seal  the 
small  skin  incision  with  cotton  and  collodion. 

Precautions. — (i)  Strict  asepsis  is  imperative;  (2) 
don't  withdraw  more  than  30  c.c.  of  fluid  at  most; 
(3)   don't  permit  the  pressure  within  the  canal  to 


198  MINOR  AND  EMERGENCY  SURGERY 

fall  below  nonnal ;  (4)  aspiration  is  not  required  and 
may  be  dangerous;  (5)  avoid  lateral  movements  of 
the  needle  while  obtaining  fluid;  (6)  withdraw  the 
needle  slowly. 

SPINAL  ANALGESIA. 

Indications. — (i)  Cases  in  which  local  anesthesia 
cannot  be  utilized;  (2)  when  general  anesthesia  is  dis- 
tinctly contraindicated ;  (3)  as  an  auxiliary  measure  in 
major  operations  on  the  abdomen  or  lower  extremi- 
ties to  prevent  shock;  (4)  to  lessen  the  pains  of 
parturition. 

Technic. — i.  Puncture  the  vertebral  canal  as  de- 
scribed under  lumbar  puncture. 

2.  Select  and  sterilize  an  appropriate  dose  of  one 
of  the  following:  cocaine,  tropacocaine,  novocaine, 
stovaine,  eucaine,  scopolamine  or  magnesium  sul- 
phate. 

3.  Draw  into  the  syringe,  containing  the  drug  in 
powder,  a  sufficient  amount  of  cerebro-spinal  fluid. 

4.  Re-inject  as  soon  as  the  powder  is  dissolved. 

5.  Operation  may  be  commenced  within  fifteen 
minutes. 

6.  To  increase  the  upper  limit  of  analgesia,  elevate 
the  foot  of  the  bed. 

Precautions. — (i)  Boiling  decomposes  cocaine  and 
its  derivatives  and  they  are  best  sterilized  by  dis- 
solving in  sulphuric  ether  with  subsequent  evapora- 
tion of  the  latter,  as  advocated  Hy  Bainbridge ;  (2) 
be  sure  that  the  drug  employed  is  absolutely  sterile, 
of  pure  quality  and  definite  strength;   (3)  be  sure 


MINOR  OPERATIONS 


199 


that   the   needle   is   not   sHghtly   withdrawn   while 
attaching  the  syringe. 

PHLEBOTOMY  (VENESECTION). 

Indications. — To  lower  vascular  tension:  (i)  pul- 


FiG.  30. — Phlebotomy. 

monary  engorgement;  (2)  engorgement  of  the  right 
heart;  (3)  profoimd  toxemias  with  full  pulse;  (4) 
cerebral  apoplexy. 

Contraindications. — All     conditions    accompanied 
by  cardio- vascular  depression. 


200,         MINOR  AND  EMERGENCY  SURGERY 

Technic. — i.  Shave  and  cleanse  the  bend  of  the 
elbow. 

2.  Apply  a  constrictor  a  few  inches  above  the 
elbow. 

3.  Steady  the  most  prominent  vein  just  below  the 
elbow  with  the  thumb  of  the  left  hand. 

4.  Thrust  a  lancet  or  bistoury  through  the  skin 
and  about  two-thirds  of  the  diameter  of  the  vein  in  an 
oblique  direction  (Fig.  30). 

5.  Remove  the  pressure  of  the  thiunb  to  permit 
flowing. 

6.  Catch  the  blood  in  a  graduated  receptacle. 

7.  When  a  sufficient  amount  has  been  withdrawn, 
remove  the  constrictor,  place  a  gauze  pad  over  the 
wound  and  apply  a  figure-of-eight  bandage. 

Precautions. — (i)  Apply  a  broad  constrictor,  so 
that  it  will  not  cut  into  the  skin;  (2)  be  careful  that 
the  constrictor  does  not  exert  sufficient  pressure  to 
obstruct  arterial  circulation;  (3)  an  incision  carried 
too  deeply  may  wound  one  of  the  cutaneous  nerves 
or  the  brachial  artery;  (4)  vertigo  or  evidence  of 
approaching  syncope  are  positive  indications  for  the 
stoppage  of  bleeding,  even  though  the  intended 
amount  has  not  been  abstracted. 

HYPODERMOCLYSIS. 

Indications. — To  supply  the  body  with  fluid  and 
aid  renal  and  skin  elimination:  (i)  as  a  prophylactic 
measure  to  prevent  and  as  a  therapeutic  agent  in  the 
treatment  of  shock;  (2)  uremia  not  associated  with 
edema;  (3)  toxemias;  (4)  when  administration  of 
fluids  through  the  stomach  is  contraindicated. 


MINOR  OPERATIONS  201 

Contraindications. — (i)  Extremely  urgent  cases; 
(2)  edema  of  the  lungs  due  to  cardiac  or  renal  dis- 
ease; (3)  high  arterial  tension. 

Technic. — i.  Select  and  cleanse  an  area  of  skin 
just  above  the  groin,  on  the  inner  side  of  the  thigh  or 
in  the  submammary  region. 

2.  Fill  an  ordinary  glass  irrigating  apparatus, 
with  rubber  tubing  attached,  with  sterile  normal 
saline  solution  (2  drams  of  sodium  chloride  to  a 
quart  of  water)  at  a  temperature  of  116°  F. 

3.  Attach  an  aspirating  needle  to  the  free  end  of 
the  rubber  tube. 

4.  Elevate  the  needle  and  open  the  stop-cock, 
thus  freeing  the  tube  and  needle  of  air. 

5.  Introduce  the  needle  at  the  selected  site  into 
the  subcutaneous  areolar  tissue. 

6.  Elevate  the  reservoir  about  2  feet  above  the 
level  of  the  needle. 

7.  After  all  the  solution  has  been  injected,  mas- 
sage the  tumor  lightly,  from  below  upward. 

Precautions. — (i)  Remember  that  in  shock  hypo- 
dermoclysis  is  of  no  value  by  reason  of  its  bulk,  but 
good  results  accrue  by  virtue  of  its  stimulant  power 
over  the  vasomotor  system  only;  (2)  be  careful  of 
over-dosage ;  i  dram  of  saline  solution  to  each  pound 
of  the  body  weight  in  each  fifteen  minutes  is  the  limit 
of  safety;  (3)  employ  hypodermoclysis  cautiously  in 
stout-old  persons,  young  children  and  in  cases  of 
nephritis. 


B.— Hot 


202  MINOR  AND  EMERGENCY  SURGERY 

ENTEROCLYSIS. 

Indications : 

A. — Cold  (70°  F.) :  To  reduce  fever  in  sthenic  cases. 

[  diuresis. 
(i)    to  promote      -j  sweating. 

[  alimentary  elimination. 

(2)  shock. 

(3)  toxemias. 

(4)  intestinal  hemorrhage. 

(5)  intussuception. 

(6)  pelvic  exudates. 

(7)  inflammation  and  spasm  of  the  pelvic  viscera. 

(8)  infantile  convulsions. 

The  temperature  should  be  100°  to  104°,  if  in- 
creased pulse  tension  is  to  be  avoided;  105°  to  108°, 
if  increased  pulse  tension  is  not  objectionable;  and 
110°  to  120°,  if  a  rapid  increase  in  pulse  tension  and 
stimulation  of  the  heart  is  desired. 

Contraindications. — Renal  disease  with  polyuresis. 

Technic. — i.  Fill  a  fountain  syringe,  irrigator  or 
other  suitable  apparatus  with  the  solution.  The 
composition  and  quantity  of  the  solution  will  of 
course  vary  according  to  the  purpose  for  which  it  is 
to  be  administered. 

2.  Attach  a  rectal  tube  (or  soft  mbber  catheter 
for  children)  to  the  free  end  of  the  tube  leading  to  the 
reservoir. 

3.  Open  the  stop-cock  and  permit  the  entire  length 
of  tubing  to  fill  with  fluid. 

4.  Lubricate  the  tip  of  the  rectal  tube. 

5.  With  the  patient  in  the  dorsal  position  or  lying 
on  his  left  side,  insert  the  end  of  the  tube  into  the 


MINOR  OPERATIONS 


203 


rectum,  at  the  same  time  again  opening  the  stop- 
cock and  permitting  the  solution  to  flow  slowly. 

6.  Gradually  raise  the  reservoir  from  the  level  of 
the  patient  to  a  height  that  will  exert  the  desired 
pressure. 


Fig.  31. — Enteroclysis  with  Kemp's  tube. 

7.  When  the  reservoir  is  empty,   withdraw  the 
tube  slowly. 
Or 


204^         MINOR  AND  EMERGENCY  SURGERY 

2.  Attach  a  Kemp's  return  flow  tube  to  the  free 
end  of  the  tube  leading  to  the  reservoir. 

3.  Exclude  all  air, 

4.  Lubricate  the  tip  of  the  tube. 

5.  Introduce  the  Kemp's  tube  with  a  gentle  rotary- 
motion,  so  that  the  folds  of  the  mucous  membrane 
will  not  catch  in  its  fenestrations. 

6.  Attach  a  piece  of  rubber  tubing  to  the  outflow 
channel  and  conduct  to  a  suitable  receptacle  (Fig.  31). 

7.  Control  the  inflow  and  outflow  of  the  solution 
by  pinching  the  corresponding  tubes  when  necessary. 

Precautions. — (i)  Always  introduce  fluids  into  the 
intestine  slowly  to  avoid  spasm;  (2)  a  Davidson 
syringe  should  not  be  used,  because  the  flow  is  inter- 
mittent and  the  pressure  is  indeterminable;  (3)  great 
pressure  exerted  on  damaged  intestine  is  dangerous; 
it  should  never  exceed  8  pounds. 

INTRAVENOUS  INFUSION. 

Indications. — (i)  Extremely  urgent  cases  of  shock; 
(2)  to  overcome  the  collapse  from  hemorrhage;  (3) 
for  the  relief  of  various  forms  of  toxemia;  (4)  as  an 
emergency  measure  in  cases  of  edema;  (5)  to  se- 
cure rapid  and  certain  action  of  certain  medicinal 
agents. 

Technic. — i.  Place  the  thoroughly  sterilized  solu- 
tion in  a  warm  irrigator. 

2.  Sterilize  the  patient's  skin  over  one  of  the 
superficial  veins  near  the  elbow  or  over  the  internal 
saphenous  vein. 

3.  Apply  a  constrictor  immediately  above. 


MINOR  OPERATIONS 


205 


4.  Incise  the  skin  and  dissect  off  the  sheath  of  the 
vein. 

5.  Ligate  the  vein  at  the  distal  end  of  the  incision 
with  catgut. 

6.  Pass  a  second  ligature  under  the  vein  at  the 
proximal  end  of  the  incision  and  leave  it  untied. 

7.  Exclude  all  air  from  the  rubber  tubing,  con- 
nected with  the  irrigator  and  the  cannula,  by  opening 
the  stop-cock  until  a  steady  stream  is  obtained. 


Fig.  32. — -Intravenous  infusion,     a,  Distal  ligature  tied  and  cut;  b, 
proximal  ligature  tied  temporarily  about  the  vein  and  cannula. 

8.  Incise  the  distended  vein  and  quickly  insert  the 
cannula,  with  the  solution  running. 

9.  Tie  the  loose  ligature  around  the  cannula  and 
overlying  vein  with  a  single  knot  (Fig.  32). 

10.  When  the  cannula  is  withdrawn,  tighten  the 
ligature  around  the  vein  and  secure  with  a  double 
knot. 

1 1 .  Divide  the  vein  between  the  two  ligatures. 


2o6  MINOR  AND  EMERGENCY  SURGERY 

12.  Suture  the  skin  wound. 

13.  Apply  a  suitable  dressing. 

Precautions. —  (i)  Taste  the  solution  before  ster- 
ilizing, if  saline  solution  is  being  used;  a  large 
quantity  of  plain  water  injected  into  a  vein  will 
cause  rapid  disintegration  of  the  red  blood-corpuscles 
and  subsequent  death ;  (2)  the  temperature  of  the 
solution  should  never  be  less  than  100°  F. ;  (3)  be 
sure  that  all  air  is  excluded  from  the  tubing  and 
cannula  and  that  no  air  enters  the  vein  at  any  stage 
of  the  operation ;  (4)  always  use  a  well  diluted  solu- 
tion of  a  drug  and  introduce  it  slowly ;  a  quart  should 
require  half  an  hour;  (5)  dip  the  cannula  in  saline 
solution  before  inserting  to  prevent  a  few  drops  of 
blood  from  coagulating  on  its  tip;  (6)  don't  try  to 
enter  a  vein  with  a  sharp  needle  without  incising 
the  skin;  blind  surgery  is  never  justifiable. 

DIRECT  TRANSFUSION. 

Indications. — (i)  To  replace,  in  whole  or  in  part, 
loss  of  normal  blood;  (2)  prolonged  shock;  (3)  ane- 
mias; (4)  general  debility;  (5)  toxemias. 

Contraindications. — When  a  healthy  donor  can- 
not be  obtained. 

Technic. — i.  Place  the  donor  and  donee  on  paral- 
lel tables. 

2.  Observe  all  aseptic  and  antiseptic  precautions. 

3.  Secure  skin  anesthesia  by  infiltration  with 
cocaine  solution. 

4.  Expose  and  free  about  3  cm.  of  the  radial  artery 
of  the  donor,  collateral  branches  being  ligated  when 
necessary. 


MINOR  OPERATIONS 


207 


5.       Expose  and  free  about  3  cm.  of  the  median 
cephalic  vein  of  the  recipient. 

6.  Place  a  permanent  ligature  peripherally  on 
each  blood-vessel, 

7.  Apply  a  Crile  compression  clamp,  one  arm  being 
rubber  shod,  as  near  as  possible  to  the  proximal  end 
of  each  exposed  vessel. 

8.  Divide  the  vessels  with  sharp  scissors,  just 
above  the  distal  ligatures. 

9.  Select  a  suitable  sterile  Brewer's  glass  tube, 
about  2  inches  in  length  and  with  a  slight  bulbous 
tip  at  each  end,  which  are  made  in  various  calibers 
and  are  straight,  curved  and  angulated. 

10.  Immerse  the  tube  in  melted  paraffin  until  all 
air  bubbles  cease  to  rise. 

11.  A  quick  sharp  shake  dislodges  excess  paraffin. 

12.  Remove  the  paraffin  on  the  exterior  of  the 
tube. 

13.  Insert  the  smaller  end  into  the  artery  and  tie 
a  ligature  around  it,  so  that  the  ligature  lies  in  the 
groove  beside  the  bulbous  tip. 

14.  Release  the  pressure  of  the  Crile  clamp  on  the 
artery  slightly,  permitting  arterial  blood  to  flow. 

15.  Insert  the  other  end  of  the  tube  into  the  vein 
and  tie  another  ligature  around  it. 

16.  Remove  both  hemostatic  clamps  entirely. 

17.  When  blood  has  passed  for  a  sufficient  time, 
ligate  both  artery  and  vein  and  withdraw  the  tube. 

18.  Suture  the  wounds,  and  apply  a  dressing. 
Precautions. — (i)  Direct  transfusion  should  not  be 

attempted  by  the  inexperienced,  as  a  slight  error 
may  prove  disastrous;  (2)  when  feasible,  it  is  wiser 


2d8  MINOR  AND  EMERGENCY  SURGERY 

to  supply  arterial  than  venous  blood;  (3)  test-tube 
phenomena  being  fairly  reliable,  make  a  preliminary 
test  of  the  blood  of  both  donor  and  donee  to  avoid 
possible  hemolysis;  (4)  don't  use  hemostatic  clamps 
that  exert  great  pressure  and  injure  the  walls  of  the 
blood-vessels;  the  pressure  should  be  just  sufficient 
to  obstruct  the  blood  current  temporarily;  (5) 
merely  dipping  the  Brewer's  tube  into  liquid  par- 
affin will  not  insure  complete  coating  of  the  lumen ; 
(6)  general  anesthesia  is  pemiissible  but  local 
anesthesia  advisable;  (7)  watch  the  condition  of 
both  patients  carefully;  (8)  in  case  of  threatened 
syncope,  place  the  donor  in  the  Trendelenburg 
position;  (9)  it  is  impossible  to  accurately  guage  the 
amount  of  blood  transfused,  but  pronounced  in- 
crease of  cardiac  dullness  or  sudden  dyspnea  in  the 
recipient  is  indication  for  cessation. 

CATHETERIZATION. 

Indications. — (i)  To  determine  the  contents  of  the 
bladder;  (2)  to  withdraw  urine  in  emergencies;  (3) 
to  evacuate  blood-clots,  fragments  of  stone  or  foreign 
bodies;  (4)  to  cleanse  the  bladder;  (5)  to  introduce 
medicaments;  (6)  as  a  preliminary  to  abdominal 
operations;  (7)  to  distend  the  bladder  with  water  or 
air;  (8)  to  establish  continuous  vesical  drainage;  (9) 
as  a  diagnostic  measure. 

Contraindications. —  (i)  Impermeability  of  the 
urethra;  (2)  suppression  of  urine. 

Technic. — i.  Patient  recumbent. 

2 .  Select  the  largest  soft-rubber  catheter  that  will 
readily  pass  the  external  urinary  meatus. 


MINOR  OPERATIONS 


209 


3 .  Cleanse  and  sterilize  the  hands  of  the  operator, 
instrument  and  glans  penis. 

4.  Retract  the  foreskin  and  grasp  the  glans  with 
the  thumb  and  forefinger  of  the  left  hand,  directing 
the  penis  so  that  it  points  to  the  median  line  of  the 
anterior  abdominal  wall. 

5.  Holding  the  catheter  2  or  3  inches  behind  its 
tip,  dip  the  tip  in  a  sterile  lubricant  and  insert 
gently  into  the  meatus. 

6.  Propel  the  catheter  forward  about  a  quarter  of 
an  inch  at  a  time. 

7.  As  the  tip  enters  the  membranous  urethra,  de- 
press the  distal  end  of  the  instrument  and  as  the  tip 
enters  the  bladder  the  exposed  end  should  lie  parallel 
with  the  extended  thighs. 

8.  If  an  obstruction  is  encountered  during  the 
passage  of  the  instrument,  it  should  be  slightly  with- 
drawn and  another  effort  made  to  pass  it.  An  im- 
passable barrier  will  necessitate  the  use  of  a  catheter 
of  smaller  size  or  one  of  metal,  depending  upon  the 
existing  circumstances. 

Precautions.^ — (i)  Be  sure  that  the  soft-rubber 
catheter  is  not  hard  and  brittle ;  (2)  a  rigid  catheter, 
in  inexperienced  hands,  is  a  dangerous  instrument 
and  should  not  be  employed  unless  the  soft-rubber 
one  fails  and  patency  of  the  urethra  is  certain;  (3) 
the  utmost  gentleness  should  be  observed  in  passing 
catheters ;  they  cannot  be  forced  through  the  urethra 
without  danger;  (4)  a  false  passage  is  evidenced  by 
sudden  obstruction  and  great  pain;  hemorrhage  fol- 
lows withdrawal  of  the  instrument;  (5)  patience  and 
gentle  persistence  will  overcome  spasmodic  stricture ; 
14 


2IO  MINOR  AND  EMERGENCY  SURGERY 

(6)  continuous  catheterization  is  preferable  to  fre- 
quent introduction  and  withdrawal;  (7)  the  catheter 
should  fill  but  not  dilate  the  urethra;  (8)  catheteri- 
zation will  dissipate  many  abdominal  "tumors"; 
(9)  don't  try  to  catheterize  women  by  the  sense  of 
touch  only;  infection  or  injury  may  be  the  price  of 
false  modesty;  (10)  a  preliminary  dose  of  hexa- 
methylenamine  is  an  excellent  prophylactic  measure, 
as  it  renders  the  urine  more  or  less  aseptic. 

VACCINATION. 

Indications. — (i)  As  a  prophylactic  measure  in  the 
prevention  of  small-pox;  (2)  to  attenuate  the  viru- 
lence of  an  attack  of  small-pox;  (3)  to  propagate  the 
virus  of  vaccinia. 

Contraindications. — (i)  Impaired  general  health; 
(2)  acute  diseases  other  than  small-pox. 

Technic. — i.  Select  and  surgically  cleanse  a  suit- 
able site  on  the  skin,  being  careful  to  avoid  the  bellies 
of  underlying  muscles.  The  insertion  of  the  deltoid 
muscle  and  inner  condyle  of  the  femur  are  the  loca- 
tions usually  chosen. 

2.  Stretch  the  skin,  with  the  forefinger  and  thumb 
of  the  left  hand. 

3.  Make  a  number  of  criss-cross  scratches  on  the 
skin,  denuding  an  area  about  a  quarter  of  an  inch  in 
diameter,  of  its  superficial  epithelia,  with  a  scarifier 
or  steel  needle,  which  has  been  sterilized  by  passing 
through  a  flame. 

4.  Break  off  the  end  of  a  small  aseptically  sealed 
capillary  tube  containing  glycerinated  animal  lymph. 

5 .  Attach  the  section  of  small  rubber  tubing  which 
accompanies  the  glass  tube  to  its  free  end. 


MINOR  OPERATIONS  211 

6.  Break  off  the  other  end  of  the  glass  tube. 

7.  Blow  through  the  rubber  tube,  depositing  the 
virus  on  the  scarified  area. 

8.  Rub  in  gently  with  the  instrument. 

9.  After  drying  thoroughly,  apply  a  suitable  shield. 

10.  If  unsuccessful,  revaccinate  in  two  weeks. 
Precautions. — (i)  If  the  virus  is  inoculated  over  a 

muscle,  the  region  is  irritated  by  the  movements 
of  the  muscle ;  (2)  large  and  multiple  denudations  are 
unnecessaiy;  (3)  the  skin  should  be  scratched  until 
lymph  exudes  but  never  deeply  enough  to  cause 
bleeding;  (4)  the  virus  should  be  active  and  free 
from  other  pathogenic  organisms,  not  long  in  stock 
and  kept  in  a  cool  place ;  (5)  the  virus  obtained  in  the 
hermetically  sealed  tubes  is  likely  to  be  cleaner  and 
more  potent  than  that  dried  on  ivory  points;  (6) 
the  patient's  underclothes  must  be  clean ;  the  shield 
may  be  dispensed  with  in  patients  whose  habits  are 
cleanly. 

SKIN-GRAFTING. 

Indications.— (i)  To  cause  prompt  healing  of  large 
granulating  surfaces,  preventing  the  deformities  that 
result  from  natural  reparative  processes  and  subse- 
quent contraction  of  the  scars;  (2)  to  replace  scar 
tissue  with  a  soft  pliable  integument;  (3)  plastic 
operations. 

Contraindications. — Devitalized  or  necrotic  sur- 
faces. 

Technic. — i.  Wash  the  granulating  surface  with 
saline  solution  and  dry  with  sterile  gauze. 

2.  Cleanse  the  area  from  which  the  grafts  are  to 


212  MINOR  AND  EMERGENCY  SURGERY 

be  taken  with  soap  and  hot  water  and  flush  with 
saline  solution. 

3.  Select  a  keen  edged  razor,  ground  flat  on  one 
side. 

4.  Sterilize  the  razor  by  immersing  in  alcohol  for 
ten  minutes. 

5.  Wrap  the  thumb  and  forefinger  of  the  operator's 
left  hand  in  sterile  gauze  and  stretch  the  skin. 

6.  Cut  a  thin  graft  from  the  stretched  skin  with  a 
quick  sawing  motion  of  the  razor,  being  careful  to 
remove  the  epidermis  only. 

7.  Transfer  the  grafts  directly  from  the  razor  to 
the  granulating  surface. 

8.  Repeat  until  the  entire  area  is  covered,  the 
grafts  over-lapping  each  other  and  the  skin  margins. 
They  may  be  teased  into  position  with  a  sterile  probe. 

9.  Press  out  all  air  bubbles  with  the  probe. 

10.  Cover  with  a  strip  of  sterile  gutta-percha 
tissue  and  leave  for  a  week. 

1 1 .  Cover  the  gutta-percha  tissue  with  a  generous 
layer  of  sterile  gauze  wrung  out  in  hot  saline  solution. 

12.  Change  the  wet  gauze  daily,  being  careful  not 
to  disturb  the  gutta-percha  tissue. 

Precautions. — (i)  Don't  graft  until  healing  has 
begun  and  the  surface  is  well  granulated;  (2)  trim 
off  exhuberant  granulations  with  a  sharp  razor;  (3) 
take  the  skin  from  the  patient  himself  when  possible ; 
(4)  never  employ  local  anesthesia;  if  anesthesia  is 
absolutely  necessary,  use  a  general  anesthetic;  (5) 
skin-grafting  must  be  an  aseptic  operation;  anti- 
septics are  contra-indicated. 


INDEX 


Abdomen,   contused  wounds, 

37 
gunshot  wounds  of,  47 
paracentesis  of,  195 
wounds    of,    protrusion    of 
intestine  in,  34 
Abscess,  123 

method  of  opening,  127 
pointing  of,  125 
Accidental  wounds,  23 
Acid,   carbolic,   in  erysipelas, 
136 
in  wet  dressings,  3  2 
subcutaneous   injections, 
in  carbuncles,  129 
Adrenalin    chlorid    in    shock, 

174,  175 
in    superficial     bleeding, 
129 
Ambulance ,  removal  of  pati- 
ent to,  19,   20 
surgeon,  19 

rules  for,  20-22 
Ammonia  in  shock,  175 
Amputations,   traumatic,    106 
after-treatment,  113 
anesthesia  in,  no 
conservative   surgery   in, 

no 
drainage  in,  112 
emergency  treatment,  107 
operative  treatment,   108 


Analgesia,  spinal,  198 
indications,  198 
precautions,  198 
technic,  198 
Anesthesia,  ethyl  chloride,  191 
contraindications,  191 
indications,  191 
precautions,  192 
technic,  191 
in  compound  fractures  and 
traumatic     amputations, 
1 10 
in  shock,  172 
infiltration,  189 
of  site  of  incision  in  local- 
ized pyogenic  infections, 
126 
skin-infiltration,  189 
contraindications,  189 
indications,  189 
precautions,  191 
technic,  190 
spinal,  198 

indications,  198 
precautions,  198 
technic,  198 
Ankle,  sprains  of,  emergency 
treatment,  54 
strapping,  54 
Ankylosis   complicating  frac- 
tures, 122 
in  dislocations,  63 

!I3 


214 


INDEX 


Antitoxin,  tetanus,  138 
Arm,  nerves  of,  injury  to,  in 

fractures  of  humerus,  86 
Arthritis,  traumatic,  51 

treatment  of,  52 
Artificial  respiration,  180 
contraindications,  180 
faradization,  182 
indications,  180 
Laborde's  method,  181 
precautions,  182 
Schafer's  method,  180 
Sylvester'  s    method,  180 
Aspiration,  193 

contraindications,  193 
indications,  193 
precautions,  194 
technic,  193 
Auditory  canal,  external,  for- 
eign bodies  in,  163 
Avulsion  of  scalp,  41 


Back,  sprained,  53 

strapping  of,  56 
Bandage,  Barton,  80 

Velpeau,     in     fracture       of 
clavicle,  84 
Bandages  for  fractures,  67 

sterilization  of,  35 
Bandaging,  32 
Barton's  bandage,  80 
Bed-sores,  156 

prevention  of,  157 
Benzine  for  dissolving  grease, 

40 
Bichloride  of  mercury  as  wet 

dressing,  32 
Bier's  hyperemia  in  localized 
pyogenic  infections,  128 
in  wounds,  34 


Bites,     rabid     animal,     treat- 
ment, 44 
snake,  treatment  of,  44 
Bladder,    catheterization     of, 
208 
rupture  of,   in  fractures   of 
pelvis,  94 
Blocking    nerve    with    cocain 
in  compound  fractures 
and  traumatic  amputa- 
tions, 110 
to  prevent  shock,  171 
Blood  transfusion,  206 

contraindications,  206 
in  collapse,  176 
indications,  206 
precautions,  207 
technic,  206 
Boil,  123 
Bones,   metacarpal,   fractures 

of,  93 

of  foot,  fractures  of,  105 
Bullet  wounds,  45 
Bunion,  49 

treatment,  49 
Burns,  140 

complications  of,  treatment, 

145 
constipation  in,  treatment, 

146 
constitutional      effects      of, 

treatment,  145 
due     to     chemical     agents, 

treatment,  145 
electric,  141,  144 
exhaustion  from,  treatment, 

147 
first  degree,  141 

treatment,  142 
inflammation   of    viscera 

from,  146 


INDEX 


215 


Burns,  renal  congestion  from, 
treatment,  146 

second  degree,  141 
treatment,  142 

shock  from,  treatment,   146 

sun,  142 

symptoms  of,  140 

third  degree,  141,  144 

treatment  of,  local,  142 

x-ray,  141 

treatment  of,  145 
Burrow's  solution,  131 
Bursitis,  49 

chronic,  49 

prepatellar,  49 

serous,  49 
chronic,  49 

suppurative,  49 

syphilitic,  49 

tubercular,  49 

types  of,  49 

Callus,    formation    in    frac- 
tures, 120 
Carbolic  acid  in  erysipelas,  136 

wash,  32 
Carbuncle,  124 

method  of  opening,  127 
Catgut,     iodine,     preparation 

of,  28 
Catheterization,  208 

contraindications,  208 

indications,  208 

precautions,  209 

technic,  208 
Cellulitis,  124 

incisions  in,  127 
Certificate,  death,  179 
Chemical  agents,  burn  due  to, 

treatment,  145 
Chilblain,  149 


Chilblain,  treatment  of,  149 
Clavicle,  fractures  of,  83 
Sayre  dressing  in,  83 
Velpeau  bandage  in,  84 
Cocaine,  nerve  blocking  with, 

to  prevent  shock,  171 
Coccygodynia,  63 
Coin-catcher,  167 
Cold,  intense,  effects  of,  140 
Coley's  fluid,  136 
Collapse,  168 

blood  transfusion  in,  176 
causes  of,  169 
diagnosis  of,  170 
due  to  hemorrhage,   treat- 
ment, 176 
factors,  predisposing  to,  169 
from  sudden  withdrawal  of 
large  amount  of  fluid,  177 
manifestations  of,  170 
oxygen  in,  176 
prevention  of,  171 
saline  solution  in,  176 
symptoms  of,  170 
treatment  of,  172,  176 
CoUes'  fracture,  91 

Plaster-of-Paris    dressing 

for,  92 
treatment,  91 
Compound  fractures,  106.   See 

also  Fractures,  compound 
Condyloid   fractures   of  hum- 
erus, treatment,  88 
Congestion,  renal,  from  burns, 

treatment,  146 
Constipation  in  burns,  treat- 
ment, 146 
Contused  wounds,  36 
drainage,  38 
dressings,  37 
hematoma  in,  36 


2l6 


INDEX 


Contused  wounds  of  abdomen, 

37 

of  scalp,  36 
sloughing  in,  38 
Coronoid  process  of  ulna,  frac- 
tures, treatment  of,  93 
Cut-throat,  41 
treatment  of,  42 

Death,  177 

care  of  patient  before,  177 

certificate,  179 

signs  of,  178 
Deformed  union  of  fractures, 

120 
Deformity,  gun-stock,  in  frac- 
tures of  humerus,  88 
Delayed  union  of  fractures,  1 1 6 
Dislocations,  57 

ankylosis  in,  63 

at  elbow,  59 

at  shoulder-joint,  58 

examination  of,  58 

infracotyloid,  60 

of  hip,  59 

of  jaw,  58 

of  radius  and  ulna,  59 

of  thumb,  59 

perineal,  60 

subacromial,  59 

subclavicular,  59 

subglenoid,  59 

subspinous,  59 

supracoracoid,  59 

supracotyloid,  60 

traumatic,  57 

treatment  of,  60 
Drain,  Peple's,  130 
Drainage  in   compound   frac- 
tures, 112 

of  contused  wounds,  38 


Drainage  of  lacerated  wounds 
of  scalp,  41 
of  localized  pyogenic  infec- 
tions, 129 
of  punctured  wounds,  43 
of  wounds,  26,  31 
tubes,  incisions  for,  39 
Dressing,  gauze,  of  wounds,  3  i 
of  contused  wounds,  37 
of  lacerated  wounds,  41 
permanent,  of  fractures,  67 
plaster-of-Paris,   for   Colles' 

fracture,  92 
primary,  of  wounds,  31 
Sayre,  in  fractures  of  clav- 
icle, 83 
Dupuytren's  splint,  105 
Dusting  powders,  36 

Ear,  foreign  bodies  in,  163 
Edema  in  fractures,  122 
Elbow,  dislocations  at,  59 
Electric  burns,  141,  144 

current    for    production    of 
artificial  respiration,    182 
Enteroclysis,  202 

contraindications,  202 

in  shocks,  174 

indications,  202 

precautions,  203 

technic,  202 

with  Kemp's  tube,  204 
Ergotole  in  shock,  175 
Erysipelas,  135 

effect  of,  on  sarcoma,  136 

facial,  135 

phlegmonous,  135 
Erysipelatoid      lymphangitis, 

135 
Esophagus,  foreign  bodies  in, 

166 


INDEX 


217 


Ethyl  chloride  anesthesia,  191 
contraindications,  191 
inlocalizedp  yogenic  in- 
fection, 126 
indications,  191 
precautions,  192 
technic,  191 
Exhaustion  from  burns,  treat- 
ment, 147 
heat,  147 

and  insolation, differentia- 
tion, 148 
treatment  of,  149 
Extension  apparatus  for  frac- 
tures, 68,  69 
Eye,  foregin  bodies  in,  161 
removal,  162 

FACiAL'erysipelas,  135 

Fainting,  168 

Faradization     as     means     of 

artificial  respiration,  182 
Femur,  fractures  of,  95 

in     infants     and     young 

children,  98 
neck,  96 
seperation   of   epiphyses, 

97 
shaft,  97 
Fibrous    union    of    fractures, 

119 
Fibula  and  tibia,  fractures  of, 
102 
fractures  of,  lower  end,  104 
separation   of   epiphyses, 

104 
shaft,  104 
upper  end,  104 
Fluid,  Coley's,  136 
Foot,  bones  of,  fractures,  105 
Forearm,  fractures  of,  89 


Foreign  bodies,  159 

beneath  nail,  removal, 
161 
in  ear,  163 
in  esophagus,  166 
in  external  auditory 

canal,  163 
in  eye,  161 

removal,  162 
in  larynx,  164,  165 
in  nose,  164 
in  pharynx,  164 
in   subcutaneous   tissues, 

160 
in  trachea,  164,  165 
in  wounds,  24 
removal,  28 
X-ray  for  detecting,  2  5 
Quain's    method    of     re- 
moving, 161 
X-rays  in  locating,  160 
Fractures,  64 

accompanying  wounds,  25 
ankylosis  complicating,  122 
bandages  for,  67 
callus  formation  in,  120 
Colles',  91 

plaster-of-Paris    dressing 

for,  92 
treatment  of,  91 
compound,  106 

after-treatment,  113 
conservative   surgery   in, 

no 
drainage  in,  112 
emergency  treatment,  107 
fixation  of  bone  fragments 

in,  III 
operative  treatment,  108 
deformed  union,  120 
delayed  union,  116 


2l8 


INDEX 


Fractures,  edema  in,  122 
emergency  treatment,  66 
examination  of,  64 
extension     apparatus     for 

68,  69 
fibrous  union,  119 
fixation  by  extension,  68 
gunshot,  of  skull,  78 
immobilization    plus    mas- 
sage, 69 
injury  to  nerves  in,  120 
involving  nose  and  mouth, 

78 
loss  of  function  in,  121 
non-union  of,  117 
causes,  117,  118 
syphilis  as  cause,  117 
of  bones  of  foot,  105 
of  clavicle,  83 

Sayre  dressing  in,  83 
Velpeau  bandage  in,  84 
of  femur,  95 

in     infants     and     young 

children,  98 
neck,  96 
separation   of   epiphyses, 

97 
shaft,  97 
of  fibula,  lower  end,  104 
separation   of   epiphyses, 

104 
shaft,  104 
upper  end,  104 
of  forearm,  89 
of  humerus,  85 

condyloid,   treatment  of, 

88 
gun-stock    deformity    in, 
88 


injury  to  nerves  of 
in,  86 


arm 


Fractures   of  humerus,  Jones' 
position  in,   88 
lower  end,  treatment,  87 
shaft,  treatment  of,  87 
of  jaw,  78,  79 
of  knee-cap,  98 
of  legs,  102 

of  metacarpal  bones,  93 
of  patella,  98 
treatment,  99 

consevative,  99,  100 
radical,  99,  loi 
of  pelvis,  94 

rupture  of  bladder  in,  94 
of  urethra  in,  95 
of  radius  and  ulna,  89 
treatment,  90 
shaft,  treatment,  90 
treatment,  90 
of  ribs,  81 
of  skull,  71 
diagnosis,  72 
prognosis,  73 
treatment,  73 
of  spine,  81 
of  tibia,  104 
and  fibula,  102 
separation   of   epiphyses, 
103 
of    ulna,    coronoid   process, 
treatment,  93 
olecranon  process,  treat- 
ment, 93 
shaft,  treatment  of,  93 
styloid  process,  treat- 
ment, 93 
open  operation,  69 
permanent  dressing  of ,  67 
Pott's,  104 
pressure  sores  in,  121 
refracture  of,  120 


INDEX 


219 


Fractures,  rupture  of  skin  and 
soft  parts  in,  121 

sepsis  after,  1 14 

sequels  of,  116 

simple,  64 

sloughing  of  skin   and  soft 
parts  in,  121 

splints  for,  67 

sprain,  52 

ununited,  117 

causes  of,  117,  118 

X-rays  in  examination,   65 
Frost-bite,  149 
Function,  loss  of,  in  fractures, 

121 
Furuncle,  123 

Gangrene  in  wounds,  24 
Gauze     dressing   of     wounds, 

31 

Gibney's   method  of  treating 

sprained  ankle,  54 
Glycerine  as  aid  to  wet  dress- 
ing, 32,  113 
Grafting,  skin-,  211 
contraindications,  211 
indications,  211 
precautions,  212 
technic,  211 
Gunshot    fractures    of    skull, 
treatment,  78 
wounds,  45 

of  abdomen,  47 
tetanus  from,  45 
X-rays  in,  46,  47 
Gun-stock  deformity  in  frac- 
tures of  humerus,  88 

Hands,  sterilization  of,  35 
Harrington's  solution,  iii 


Heat  exhaustion,  147 

and    insolation,    differen- 
tiation, 148 
treatment,  149 
intense,  effects  of,  140 
Hematoma    in    contused 

wounds,  36 
Hemorrhage,  collapse  due  to, 
treatment,  176 
from  wounds,  24 
control  of,  26 
Hip,  dislocations  of,  59 
House  staff,  17,  18 
Housemaid's  knee,  49 
Humerus,  fractures  of,  85 

condyloid,   treatment  of, 

88 
gun  stock  deformity  in,  88 
injury  to  nerves  of  arm 

in,  86 
Jones'  position  in,  88 
lower  end,  treatment,  87 
shaft,  treatment,  87 
Hydrogen  peroxide,  irrigation 

of  wounds  with,  27 
Hyperemia,  Bier's,  in  wounds, 
34 
in  localized  pyogenic  infec- 
tions, 127,  128 
Hypodermic  injections,  187 
contraindications,  187 
dangers,  189 
indications,  187 
precautions,  189 
technic,  187 
Hypodermoclysis,  200 
contraindications,  201 
in  shock,  174 
indications,  200 
precautions,  201 
technic,  201 


2^20 


INDEX 


Hysterical  joints,  48 

IcHTHYOL  in  erysipelas,  136 

Incised  wounds,  41 

Incisions  for  drainage  tubes, 

39 
in  localized  pyogenic  infec- 
tions, 126 
Infected  wounds,  44 
Infections,    pyogenic,      acute, 
123 
localized,  123 

after-treatment,  132 
anesthesia    of     site     of 

incision  in,  126 
drainage  in,  129 
hyperemia  in,  127,  128 
incisions  in,  126 
method    of    expressing 

pus,  128 
sterilization  in,  128 
systemic  disturbances  in, 

131 
treatment  of,  125 
systemic,  132 

serum-therapy  in,    133 
special,  135 
Infiltration  anesthesia,  189 
Inflammation  of  joints,  48 

of  viscera  from  burns,   146 
Infracotyloid  dislocations,  60 
Infusion,  intravenous,  203 
indications,  203 
precautions,  206 
technic,  204 
Insolation,  147 

and  heat  exhaustion,  differ- 
entiation, 148 
Instruments,    sterilization   of, 

35 
Interne,  17,  18 


Intravenous  infusion,  203 
in  collapse,  176 
in  shock,  1 74 
indications,  203 
precautions,  206 
technic,  204 
Iodine  catgut  preparation,  28 
in  erysipelas,  136 
tincture  of,  in  localized  py- 
ogenic infections,  129 
injection,  into  wounds,  31 
Iodoform  as  dusting  powder, 

36 
Irrigation,  continuous,  in  com- 
pound fractures,  1 14 
of    wounds   with   hydrogen 
peroxide,  27 

Jaw,  dislocations  of,  58 

fractures  of,  78,  79 
Joints,  hysterical,  48 

inflammations  of,  48 

traumatic  injuries,  48 
Jones'  position  in  fractures  of 

humerus,  88 

Kemp's      tube,      enteroclysis 

with,  204 
Kidneys,  congestion  of,  from 

burns,  treatment,  146 
Knee,  housemaid's,  49 
Knee-cap,  fracture  of,  98 


Laborde's  method  of  artificial 

respiration,  181 
Lacerated  wounds,  39 

dressing,  41 

of  scalp,  drainage,  41 

treatment,  40 


INDEX 


221 


Laryngotomy,  183 

contraindications,  183 

indications,  183 

precautions,  184 

technic,  183 
Larynx,  foregin  bodies  in,  164, 

165 
Leg,  fractures  of,  102 
ulcer  of,  151 
strapping,  154 
Liquor    ammonii    acetatis    in 
renal     congestion     from 
burns,  146 
Lockjaw,  137 
Lumbar  puncture,  196 
indications,  196 
precautions,  197 
technic,  197 
Luxatio  erecta,  59 
Lymphangitis,     erysipelatoid, 

Magnesium  sulphate  in  tet- 
anus, 138 

Massage  in  fractures,  69 

Mercury,  bichloride  of,  as  wet 
dressing,  32 

Metacarpal    bones,    fractures 

of.  93 
Minor  operations,  180 
Morphine  in  burns,  146 

in  shock,  175 
Mouth     and     nose,     fractures 

involving,  78 

Nail,    foreign  body  beneath, 

removal,  160 
Nerve  blocking  with   cocaine 

to  prevent  shock,  171 
Nerves,  injury  to,  in  fractures, 
120 


Nerves,  of  arm,  injury  to,  in 
fractures  of  humerus,  86 

Non-union  of  fractures,  117 
causes,  117,  118 

Nose    and    mouth,     fractures 
involving,  78 
foreign  bodies  in,  164 

Olecranon  process  of  ulna, 

fractures,  treatment  of,  93 

Operations  during  shock,  172 

minor,  180 
Oxygen  in  collapse,  176 

Paracentesis  abdominis,  195 
contraindications,  195 
indications,  195 
precautions,  196 
technic,  195 
Patella,  fractures  of,  98 
treatment,  99 

conservative,  99,  100 
radical,  99,  loi 
Patient,  removal  of,  to  ambu- 
lance, 19,  20 
Pelvis,  fractures  of,  94 

rupture  of  bladder  in,  94 
of  urethra  in,  95 
Penetrating  wounds,  43 
Peple's  drain,  130 
Perforating  wounds,  43 
Perineal  dislocations,  60 
Pharynx,    foreign    bodies    in, 

164 
Phlebotomy,  199 

contraindications,  199 
indications,  199 
precautions,  200 
technic,  200 
Phlegmonous   erysipelas,    135 


2?2 


INDEX 


Plaster-of-Paris    dressing    for 

Colles'  fracture,  92 
Pointing  of  abscess,  125 
Poisoned  wounds,  44 
Pott's  fracture,  104 

puffy  tumor,  36 
Poultices,  125 
Powder  grains,  removal,  46 
Powders,  dusting,  36 
Prepatellar  bursitis,  49 
Pressure  sores  in  fractures,  121 
Probing  for  foreign  bodies,  160 

of  wounds,  24 
Puffy  tumor.  Pott's,  36 
Puncture,  lumbar,  196 
indications,  196 
precautions,  197 
technic,  197 
of  abdomen,  195 
Punctured  wounds,  43 

drainage,  43 
Pus,    localized    collections   of, 
123 
evacuation,  128 

curettage    of    cavity 
after,  128 
treatment,  125 
Pyogenic     infections,     acute, 
123 
localized,  123 

after-treatment,  132 
anesthesia    of    site    of 

incision  in  126 
drainage  in,  129 
hy[)eremia  in,  127,  128 
incisions  in,  126 
method    of    expressing 

pus,  128 
sterilization  in,  128 
systemic     disturbances 
in,  131 


Pyogenic  infections,  localized, 
treatment  of,  125 
systemic,  132 

serum-therapy  in,    133 
treatment  of,  133 

Quain's  method  of  removing 
foreign  bodies,  161 

Rabid  animal,  bite  of,  treat- 
ment, 44 
Radius  and  ulna,  dislocations 

of>  59 
fractures  of,  89 
treatment,  90 
fractures    of    shaft,    treat- 
ment, 90 
treatment,  90 
Refracture,  120 
Renal  congestion  from  burns, 

treatment,  146 
Resident,  18 

Respiration,  artificial,  180 
contraindications,  180 
faradization     as     means, 

182 
indications  for,  180 
Laborde's  method,   181 
precautions  in,  182 
Schafer's  method,  180 
Sylvester's  method,  180 
Ribs,  fractures  of,  81 
Rules  for  ambulance  surgeon, 

20—22 
Rupture   of   bladder   in   frac- 
tures of  pelvis,  94 
of   skin    and    soft   parts   in 

fractures,  121 
of   urethra   in   fractures   of 
pelvis,  95 


INDEX 


223 


Saline  solution  in  collapse,  176 

in  shock,  174 
Sacroma,  effects  of  erysipelas 

on,  136 
Sayre  dressing  in  fractures  of 

clavicle,  83 
Scalp,  avulsion  of,  41 

contused  wounds  of,  36 

lacerated  wounds  of,  drain- 
age, 41 
Schafer's  method  of  artificial 

respiration,  180 
Sepsis  after  fractures,  114 
Sequels  of  fractures,  116 
Serous  bursitis,  49 

chronic,  49 
Serum  treatment  of  systemic 

infections,  133 
Shaving  of  surrounding  skin 

in  wounds,  27 
Shock,  168 

adrenalin  chloride  in,    174, 

175 
ammonia  in,  175 
causes  of,  169 
diagnosis  of,  170 
enteroclysis  in,  174 
ergotol  in,  175 
factors  predisposing  to,  169 
from  burns,  treatment,  146 
from  wounds,  24 
hypodermoclysis  in,  174 
manifestations  of,  170 
morphine  in,  175 
operating  during,  172 
prevention  of,  171 
saline  solution,  174 
symptoms  of,  170 
treatment  of,  172 
Shoulder-joint,  dislocations  at, 
58 


Signs  of  death,  178 
Skin   and  soft  parts,   rupture 
and  sloughing,  in  fractures, 
121 
Skin-grafting,  2  1 1 

contraindications,  2  1 1 
indications,  211 
precautions,  212 
technic,  211 
Skin-infiltration       anesthesia, 
189 
contraindications,  189 
indications,  189 
precautions,  191 
technic,  190 
Skull,  fractures  of,  71 
diagnosis,  72 

differential    diagnosis    of 
associated     brain     in- 
juries, 74,  75,  76,  77 
prognosis,  73 
treatment,  73 
gunshot  fractures,  78 
Sloughing     in      contused 
wounds,  38 
in  wounds,  23 

of  skin    and    soft    parts    in 
fractures,  121 
Snake  bites,  treatment,  44 
Solution,  Burrow's,  131 
Thiersch's,  144 
Wright's,   131 
Sores,   pressure,   in  fractures, 

121 
Spinal  analgesia,  198 
indications,  198 
precautions,  198 
technic,  198 
Spine,  fractures  of,  81 
Splint,  Dupuytren's  105 
Splints  for  fractures,  67 


224 


INDEX 


Sprained  back,  53 
strapping,  56 
Sprain-fracture,  52 
Sprains,  52 

after-treatment,  56 

emergency  treatment,  53 

of  ankle,   emergency  treat- 
ment, 54 
strapping,  54 
Sterilization  in  localized  pyo- 
genic infections,  128 

of  bandages,  etc.,  35 

of  hands,  35 

of  instruments,  35 

of  wounds,  3 1 
Strapping  of  sprained  ankle,  54 

back,  56 

ulcer  of  leg,  154 
Styloid  process  of  ulna,  frac- 
tures treatment,  of,  93 
Subclavicular  dislocations,  59 
Subcutaneous  tissues,  foreign 

bodies  in,  160 
Subcuticular  suture,  29,  30 
Subglenoid  dislocations,  59 
Subspinous  dislocations,  59 
Sun  burns,  142 
Sunstroke,  147 

treatment  of,  148 
Suppurative  bursitis,  49 
Supracoracoid  dislocations,  59 
Supracotyloid  dislocations,  60 
Surgeon,  ambulance,  19 

rules  for,  20-22 
Surgical    collapse,     168.     See 
also  Collapse 

shock,  168.     See  also  Shock 

Suture  of   divided   important 

structures  in  wounds,  28 

of  wounds,  29 

subcuticular,  29,  30 


Sylvester's  method  of  artificial 

respiration,  180 
Syncope,  168 
Synovitis,  traumatic,  50 

treatment  of,  50 
Syphilis  as  cause  of  delayed 

union     of      fractures,     116, 

117 
Syphilitic  bursitis,  49 
Systemic  disturbances  in  local- 
ized pyogenic  infections, 

131 
pyogenic  infections,  132 

Tetanus,  137 
antitoxin,  138 
from  gunshot  wounds,  45 
magnesium  sulphate  in,  138 
prophylaxis  of,  138 
Thiersch's  solution,  144 
Throat,  cut-,  41 

treatment  of,  42 
Thumb,  dislocations  of,  59 
Tibia  and  fibula,  fractures  of, 
102 
fractures  of,  104 

separation   of   epiphyses, 
103 
Tincture   of   iodine    in    local- 
ized pyogenic  infections, 
129 
in  preparation  of  catgut, 

28 
injection  into  wounds,  3  i 
Trachea,    foreign    bodies    in, 

164,  165 
Tracheotomy,  185 

contraindications,  185 
indications,  185 
precautions,  186 
technic,   186 


INDEX 


225 


Transfusion,  blood,  206 

contraindications,  206 
indications,  206 
precautions,  207 
technic,  206 
Traumatic  amputations,  106 
after-treatment,  113 
conservative   surgery   in, 

no 
drainage  in,  112 
emergency        treatment, 

107 
operative  treatment,  108 
arthritis,  51 

treatment,  52 
dislocations,  57 
injuries  of  joints,  48 
synovitis,  50 
treatment,  50 
Tubercular  bursitis,  49 
Tumor,  Pott's  puffy,  36 
Turpentine    for    dissolving 
grease,  40 

Ulcers,  151 

treatment  of,  152 

varicose,  of  leg,  151 
strapping,  154 
Ulna  and  radius,  dislocations 

of,  59 
fractures  of,  89 
fractures  of    coronoid    pro- 
cess, treatment,  93 
treatment,  90 
olecranon  process,  treat- 
ment, 93 
shaft,  treatment  of,  93 
styloid      process,      treat- 
ment, 93 
Union,  deformed,  of  fractures, 


IS 


Union,   delayed,  of  fractures, 
116 
fibrous,  of  fractures,  1 1  y 

Ununited  fractures,  1 1 7 
causes  of,  117,  118 

Urethra,   rupture  of,   in  frac- 
tures of  pelvis,  95 

Vaccination,  210 

contraindications,  210 

indications,  210 

precautions,  211 

technic,  210  ^ 

Vaccine  treatment  of  infected 

wounds,  44 
Varicose  ulcer  of  leg,  151 

strapping,  154 
Velpeau  bandage  in  fractures 

of  clavicle,  84 
Venesection,  199 

contraindications,  199 

indications,  199 

precautions,  200 

technic,  200 
Viscera,    inflammation    of, 

from  burns,  146 

Wash,  carbolic,  32 
Wounds,  accidental,  23 
after-treatment,  34 
bandaging  of,  32 
Bier's  hyperemia,  in,  34 
bullet,  45 

classification  of,  23 
coaptation  of  edges,  2  9 
contused,  36 

drainage  of,  38 

dressing  of,  3  7 

hematoma  in,  36 

of  abdomen,  37 

of  scalp,  36 


226 


INDEX 


Wounds,  contused,   sloughing 

in,  38 
drainage  of,  26,  31 
dressing  of,  primary,  3 1 
emergency  treatment,  33 
examination  of,  24 
foreign  bodies  in,  24 
removal,  28 
X-ray  for  detecting,  25 
fracture  accompanying,  25 
gangrene  in,  24 
gauze  dressing,  3 1 
gunshot,  45 

of  abdomen,  47 

tetanus  from,  45 

X-rays  in,  46,  47 
hemorrhage  from,  24 

control  of,  26 
incised,  41 
infected,  44 
irrigation  of,  with  hydrogen 

peroxide,  27 
lacerated,  39 

dressing,  41 

of  scalp,  drainage,  41 

treatment  of,  40 
of  abdomen,  protrusion  of 

intestine  in,  34 
penetrating,  43 


Wounds,  perforating,  43 
poisoned,  44 
probing  of,  24 
prognosis  of,  24 
punctured,  43 

drainage  of,  43 
rest  of  injured  area,  33 
shaving  of  surrounding  skin 

in,  27 
shock  from,  24 
sloughing  in,  23 
sterilization  of,  3  i 
suture  of,  29 

divided      important 
structures  in,  28 
tincture  of  iodine  injected 

into,  3 1 
treatment  of,  25 

emergency,  t,t, 
Wright's  solution,  131 

X-RAY  burns,  treatment,   145 
for  detecting  foreign  bodies 

in  wounds,  25 
in  examination  of  fractures, 

65 
in  gunshot  wounds,  46,  47 
in  locating  foreign  bodies, 

160 


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Dr.  deSchweinitz' s  book  has  long  been  recognized  as  a  standard  authority 
upon  eye  diseases,  the  reputation  of  its  author  for  accuracy  of  statement 
placing  it  far  in  the  front  of  works  on  this  subject.  For  this  edition  Dr. 
deSchweinitz  has  subjected  his  book  to  a  most  thorough  revision.  Fifteen 
new  subjects  have  been  added,  ten  of  those  in  tlie  former  edition  have  been 
rewritten,  and  throughout  the  book  reference  has  been  made  to  vaccine  and 
serum  therapy,  to  the  relation  of  tuberculosis  to  ocular  disease,  and  to  the 
value  of  tuberculin  as  a  diagnostic  and  therapeutic  agent. 

The  text  is  fully  illustrated  with  black  and  white  cuts  and  colored  plates, 
and  in  every  way  the  book  maintains  its  reputation  as  an  authority. 

Johns  Hopkins  Hospital  Bulletin 

"  No  single  chapter  can  be  selected  as  the  best.  They  are  all  the  product  of  a  finished 
authorship  and  the  work  of  an  exceptional  ophthalmologist.  The  work  is  certainlj'  one  of 
the  best  on  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 

DeSchweinitz    and    Randall's 
Eye,  Ear,  Nose,  and  Throat 

American  Text=Book  of  Diseases  of  the  Eye,  Ear,  Nose, 
and  Throat.  Edited  by  G.  E.  deSchweinitz,  M.  D.,  and 
B.  Alexander  Randall,  M.  D.  Imperial  octavo,  1 251  pages, 
with  766  illustrations,  59  of  them  in  colors.  Cloth,  ^7.00  net; 
Half  Morocco,  ^8.50  net. 


SAUNDERS'    BOOKS   ON 


GET  A«**^*,:<%r»,«*  THE     NEW 

THE  BEST  /imCriCan  standard 

Illustrated  Dictionary 

Just  Ready— The  New  (6th)  Edition 


The  American  Illustrated  Medical  Dictionary.     A  new 

and  complete  dictionary  of  the  terms  used  in  Medicine,  Surgery, 
Dentistry,  Pharmacy,  Chemistry,  Veterinary  Science,  Nursing, 
and  all  kindred  branches;  with  over  loo  new  and  elaborate 
tables  and  many  handsome  illustrations.  By  W.  A.  Newman 
Borland,  M.D.  Large  octavo  of  985  pages.  Flexible  leather, 
^4.50  net;  with  thumb  index,  ^5.00  net. 

ENTIRELY  RESET— A  NEW  WORK  WITH  ADDED  FEATURES 

In  this  edition  the  book  has  been  subjected  to  a  thorough  revision  and 
entirely  reset,  adding  thousands  of  important  new  terms.  This  is  the  only 
up-to-date  medical  dictionary — bar  none. 

Howard  A.  Kelly,  M.D.. 

Processor  of  Gynecologic  Surgery,  Johns  Hopkins  University,  Ballimore 

"Dr.  Dorland's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Pilcher's  Practical  Cystoscopy 

Practical  Cystoscopy.  By  Paul  M.  Pilcher,  M.D.,  Con- 
sulting Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of 
398  pages,  with  233  illustrations,  29  in  colors.     Cloth,  ^5.50  net. 

JUST  READY 

To  be  properly  equipped,  you  must  have  at  your  instant  command  the 
information  this  book  gives  you.  It  explains  away  all  difficulty,  telling  you 
wky  you  do  not  see  something  when  something  is  there  to  see,  and  telling  you 
how  to  see  it.  All  theory  has  been  uncompromisingly  eliminated,  devoting 
every  line  to  practical,  needed  every-day  facts,  telling  you  how  and  when  to 
use  the  cystoscope  and  catheter — telling  you  in  a  way  to  make  you  know. 
The  work  is  complete  in  every  detail. 


EYE,    EAR,    NOSE,    AND     THROAT 


Theobald's 
Prevalent  Diseases  of  the  Eye 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald, 
M.  D.,  Clinical  Professor  of  Ophthalmology  and  Otology,  Johns 
Hopkins  University.  Octavo  of  550  pages,  with  219  text-illustra- 
tions and  10  plates.     Cloth,  $4.50  net ;   Half  Morocco,  |6.oo  net. 

Chas.  A.  Oliver.  M.  D.. 

Clinical  Professor  of  Ophthalmology ,  Woman's  Medical  College,  Phila. 
"  I  feel  I  can  conscientiously  recommend   it,  not  only  to  the  general  physician  and 
medical  student,  but  also  to  the  experienced  ophthalmologist." 


Wells*  Chemical  Pathology 

Chemical  Pathology.  By  H.  Gideon  Wells,  Ph.D., 
M.D.,  Assistant  Professor  of  Pathology  in  the  University  of  Chi- 
cago.    Octavo  of  549  pages.     Cloth,  ^3.25  net. 

Wm.  H,  Welch,  M.ID.,  Johns  Hopkins  University . 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my  students." 


Saxe's  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  DeSantos  Saxe, 
M.  D.,  Instructor  in  Venereal  and  Genito-Urinary  Surgery, 
New  York  Post-Graduate  Medical  School  and  Hospital.  i2mo 
of  448  pages,  illustrated.     Cloth,  ;^i.75  net. 

THE  NEW  (2d)  EDITION 

This  work  is  intended  as  an  aid  in  diagnosis,  by  interpreting  the  clinical 
significance  of  the  chemic  and  microscopic  urinary  findings. 

Francis  Carter  Wood,  M.  D., 

Adjunct  Professor  of  Clinical  Pathology ,  Columbia  University. 

"  It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is  indeed, 
better  than  a  good  many  of  the  larger  ones." 


SJCWDjSJ^S'    BOOK'S    OiV 


Brtihl,  Politzer,  and  Smith's 
Otology 

Atlas  and  Epitome  of  Otology.  ByGusxAV  Bruhl,  M.  D., 
of  Berlin,  with  the  collaboration  of  Professor  Dr.  A.  Politzer, 
of  Vienna.  Edited,  with  additions,  by  S.  MacCuen  Smith, 
M.D.,  Professor  of  Otology  in  the  Jefferson  Medical  College, 
Philadelphia.  With  244  colored  figures  on  39  lithographic  plates, 
99  text-illustrations,  and  292  pages  of  text.  Cloth,  ^3.00  net. 
In  Saunders'  Hand-Atlas  Series. 

The  work  is  both  didactic  and  clinical  in  its  teaching.  A  special  feature 
is  the  very  complete  exposition  of  the  minute  anatomy  of  the  ear,  a  working 
knowledge  of  which  is  so  essential  to  an  intelligent  conception  of  the  science 
of  otology. 

Clarence  J.  Blake,  M.D.. 

Professor  of  Otology  in  Harvard  Unhiersity  Medical  School,  Boston. 
"  The  most  complete  work  of  its  kind  as  yet  published,  and   one   commending  itself  to 
both  the  student  and  the  teacher  in  the  character  and  scope  of  its  illustrations." 

Haab  and  DeSchweinitz's 
Operative  Ophthalmology 

Atlas  and  Epitome  of  Operative  Ophthalmology.     By 

Dr.  O.  Haab,  of  Ziirich.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M.D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  30  colored  lithographic  plates,  154  text- 
cuts,  and  375  pages  of  text.  Cloth,  ^3.50  net.  In  Saunders' 
Hand-Atlas  Series. 


This  work  represents  the  author's  thirty  years'  experience  in  eye  work. 
The  various  operative  interventions  are  described  with  all  the  precision  and 
clearness  that  such  an  experience  brings.  Recognizing  the  fact  that  mere  verbal 
descriptions  are  frequently  insufficient,  Dr.  Haab  has  taken  particular  care  to 
illustrate  plainly  the  different  parts  of  the  operation. 

Johns  Hopkins  Hospital  Bulletin 

"  The  descriptions  of  the  various  operations  are  so  clear  and  full  that  the  volume  car 
•veil  hold  place  with  more  pretentious  text-books." 


DISEASES   OF   THE  EYE. 


Haab  and  DeSchweinitz's 
External  Diseases  qf  the  £ye 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr  O.  Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M,  D.  ,  Professor  of  Ophthalmology,  University  of 
Pennsylvania.  loi  colored  illustrations  on  46  lithographic  plates 
and  244  pages  of  text.     Cloth,  ^3.00  net.     Saunders^  Atlases. 

THE  NEW  (3d)  EDITION 

The  conditions  attending  diseases  of  the  external  eye,  which  are  often  so 
complicated,  have  probably  never  been  more  clearly  and  comprehensively 
expounded  than  in  the  forelying  work. 

The  Medical  Record,  New  York 

"  The  work  is  excellently  suited  to  the  student  of  ophthalmology  and  to  the  practising 
physician.     It  cannot  fail  to  attain  a  well-deserved  popularity." 

Haab  and  DeSchweinitz's 
Ophthalmoscopy 

Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthal- 
moscopic Diagnosis.  By  Dr.  O.  Haab,  of  Ziirich.  Edited, 
with  additions,  by  G.  E.  deSchweinitz,  M.  D.,  Professor  of  Oph- 
thalmology, University  of  Pennsylvania.  With  152  colored  litho- 
graphic illustrations  and  94  pages  of  text.  Cloth,  ^3.00  net. 
In  Saunders^  Hand- Atlas  Series. 

THE  NEW   (2d)    EDITION 

In  this  work  not  only  is  the  student  made  acquainted  with  carefully  pre- 
pared ophthalmoscopic  drawings  done  into  well-executed  lithographs  of  the 
most  important  fundus  changes,  but,  in  many  instances,  plates  of  the  micro- 
scopic lesions  are  added. 

The  Leuicet.  London 

"  We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library 
of  every  hospital  into  which  ophthalmic  cases  are  received." 


SAUNDEHS'  BOOKS  ON 


Greene  and   Brooks' 
Genito-Urinary  Diseases 

A  Text=Book  of  Genito=Urinary  Diseases.  By  Robert 
H.  Greene,  M.D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medi- 
cal School.    Octavo  of  560  pages,  illustrated.   Cloth,  $5.00  net. 

THE    NEW    (2d)    EDITION 

This  new  work  covers  completely  the  subject  of  genito-urinary  diseases, 
presenting  both  the  medical  and  surgical  sides.  Kidney  diseases  are  very  elabo- 
rately detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito- 
urinary diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and 
students." 


Gleason  on  Nose,  Throat, 
and  £ar 

A  Manual  of  Diseases  of  the  Nose,  Throat,  and  Ear.     By 

E.  Baldwin  Gleason,  M.D.,  LL.D.,  Clinical  Professor  of 
Otology,  Medico-Chirurgical  College,  Philadelphia.  i2mo  of 
563  pages,  profusely  illustrated.     Flexible  leather,  $2.50  net. 

THE  NEW  (2d)   EDITION 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  essential.     A  feature  consists  of  the  collection  of  formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  ar 
few  books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Qenito=Urinary  Diseases, 
Syphilis,  and  Diseases  of  the  Sl<in.  Edited  by  L.  Bolton 
Bangs,  M.D.,  late  Professor  of  Genito-Urinary  Surgery,  Bellevue 
University,  New  York;  and  W.  A.  Hardaway,  M.D.,  Professor 
of  Diseases  of  the  Skin,  Missouri  Medical  College.  Octavo, 
1229  pages,  300  engravings,  20  colored  plates.     Cloth,  $7.00  net. 


NOSE,   THROAT,  AND   EAR. 


GradleV 
Nose,  Pha^rynx,  and  Ear 


Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry 
Gradle,  M.  D.,  Professor  of  Ophthalmology  and  Otology,  North- 
western University  Medical  School,  Chicago.  Handsome  octavo 
of  547  pages,  illustrated,  including  two  full-page  plates  in  colors. 
Cloth,  $3.50  net;  Half  Morocco,  $5.00  net. 

This  volume  presents  diseases  of  the  Nose,  Pharynx,  and  Ear  as  the  author 
has  seen  them  during  an  experience  of  nearly  twenty-five  years.  Topographic 
anatomy  has  also  been  accorded  liberal  space. 

Pennsylvania  Medical  Journal 

"  This  is  the  most  practical  volume  on  the  nose,  pharynx,  and  ear  that  has  appeared 
recently.  ...  It  is  exactly  what  the  less  experienced  observer  needs,  as  it  avoids  the  con- 
fusion incident  to  a  categorical  statement  of  everybody's  opinion." 

Kyle's  Nose  and  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle, 
M.D.,  Professor  of  Laryngology  in  the  Jefferson  Medical  Col- 
lege, Philadelphia;  Consulting  Laryngologist,  Rhinologist,  and 
Otologist,  St.  Agnes'  Hospital.  Octavo,  797  pages;  with  219 
illustrations  and  26  lithographic  plates  in  colors.  Cloth,  $4.00 
net;  Half  Morocco,  $5.50  net. 

THE    NEW    (4th)    EDITION 

This  work  has  now  reached  its  fourth  edition.  With  the  practical  purpose 
of  the  book  in  mind,  extended  consideration  has  been  given  to  treatment,  each 
disease  being  considered  in  full,  and  definite  courses  being  laid  down  to 
meet  special  conditions  and  symptoms. 

Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  in 
vain  for  anything  he  needs." 


10  SAUNDERS'    BOOKS   ON 

Stelwa^on's 
Diseases   of    the    Skin 

A  Treatise  on  Diseases  of  tlie  Skin.  By  Henry  W. 
Stelwagon,  M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the 
Jefferson  Medical  College,  Philadelphia.  Octavo  of  1 175  pages, 
with  280  text-cuts  and  32  plates.  Cloth,  ^6.00  net;  Half 
Morocco,  $7.50  net. 

THE  NEW  (6th)  EDITION 

The  demand  for  six  editions  of  this  work  in  such  a  short  period  indi- 
cates the  practical  character  of  the  book.  In  this  edition  the  articles  on 
Frambesia,  Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  re- 
written. The  new  subjects  include  Verruga  Peruana,  Leukemia  Cutis, 
Meralgia  Paraesthetica,  Dhobie  Itch,  and  Uncinarial  Dermatitis. 

George  T.   Elliot,  M.  D.,  Professor  of  De7-matology.,  Cornell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judg- 
ment, for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of 
dermatology,  I  think  it  holds  first  place." 


Schamberg^s  Diseases  of   the 
Skin  and  Eruptive  Fevers 

Diseases  of  the   Skin   and    Eruptive   Fevers.     By  Jay 

F.  ScHAMBERG,  M.  D.,  Profcssor  of  Dermatology  and  the  In- 
fectious Eruptive  Diseases,  Philadelphia  Polyclinic.  Octavo  of 
534  pages,  illustrated.     Cloth,  $3.00  net. 

THE  CUTANEOUS   MANIFESTATIONS   OF  ALL  DISEASES 

"The  views  expressed  on  all  topics  are  conservative,  safe  to  follow,  and  practical,  and 
are  well  abreast  of  the  knowledge  of  the  present  time.     Actinotherapy  and  radiother;ip 
receive  considerably  more  than  passing  notice." — American  Journal  of  Medical  Scii-nci-. . 


DISEASES   OF   THE   S/i/iV.  tl 

Mracek  and  Steiwag'on's 
Diseases  of  the  Skin 


Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof. 
Dr.  Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
Henry  W.  Stelwagon,  M.  D.,  Professor  of  Dermatology  in 
the  Jefferson  Medical  College,  Philadelphia.  With  77  colored 
plates,  50  half-tone  illustrations,  and  280  pages  of  text.  In 
Saunders^  Hand- Atlas  Series.  Cloth,  ^4.00  net. 

THE     NEW    (2d)    EDITION 

American  Journal  of  the  Medical  Sciences 

"  The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are  : 
First,  its  handiness  ;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color,  and 
the  diagnostic  points  which  they  bring  out  " 

Mracek  and  Bangs' 
Syphilis  6  Venereal  Diseases 

Atlas  and  Epitome  of  Syphilis  and  the  Venereal  Dis= 

eases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna.  Edited,  with 
additions,  by  L.  Bolton  Bangs,  M.  D.,  late  Prof  of  Genito- 
urinary Surgery,  University  and  Bellevue  Hospital  Medical  Col- 
lege, New  York.  With  71  colored  plates  and  122  pages  of  text. 
Cloth,  $3.50  net.     In  Saunders'  Hand-Atlas  Series. 

According  to  the  unanimous  opinion  of  numerous  authorities,  the  illus- 
trations in  this  work  surpass  in  beauty  anything  of  the  kind  that  has  been  pro- 
duced, not  only  in  Germany,  but  throughout  the  literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of"  The  Avieiican  Text-Book  of  Obstetrics." 

"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and 
graphic  character  of  its  illustrations  is  the  '  Atlas  of  Syphilis  and  the  Venereal  Diseases.' 
I  know  of  nothing  in  this  country  that  can  compare  with  it." 


12  SAUNDEJiS'  BOOK'S    OJV 

Holland's 
Chemistry  and  Toxicolog'y 

A  Text=Book  of    Medical  Chemistry   and    Toxicology. 

By  James  W.  Holland,  M.D.,  Professor  of  Medical  Chemistry 
and  Toxicology,  and  Dean,  Jefferson  Medical  College,  Philadel- 
phia.    Octavo  of  635  pages,  illustrated.      Cloth,  $3.00  net. 

JUST  READY— THE  NEW  (3d)  EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  thirty-five 
years'  practical  experience  in  teaching  chemistry  and  medicine.  Recognizing 
that  to  understand  physiologic  chemistry  students  must  first  be  informed  upon 
points  not  referred  to  in  most  medical  te.\t-books,  the  author  has  included  in  his 
work  the  latest  views  of  equilibrium  of  equations,  mass-action,  cryoscopy,  os- 
motic pressure,  etc.     Much  space  is  given  to  toxicology. 

American  Medicine 

"  Its  statements  are  clear  and  terse ;  its  illustrations  well  chosen;  its  development  logi- 
cal, systematic,  and  comparatively  easy  to  follow.  .   .  .  We  heartily  commend  the  work." 

Gninwald  and  Newcomb's 
Mouth,  Pharynx,  and  Nose 

Atlas  and  Epitome  of  Diseases  of  the  Mouth,  Pharynx, 
and  Nose.  By  Dr.  L.  Grunwald,  of  Munich.  Edited,  with 
additions  by  James  E.  Newcomb,  M.  D.,  Instructor  in  Laryn- 
gology, Cornell  University  Medical  School.  With  102  illustrations 
on  42  colored  lithographic  plates,  41  text-cuts,  and  219  pages  of 
text.      Cloth,  ^3.00  net.     In  Saunders'  Hand-Atlas  Series. 

Gninwald  6  Grayson  on  Larynx 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.     By  Dr. 

L.  Grxjnwald,  of  Munich.  Edited,  with  additions,  by  Charles 
P.  Grayson,  M.  D.,  Clinical  Professor  of  Laryngology  and 
Rhinology,  University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth, 
^2.50  net.     In  Saunders'  Hand- At/as  Series. 


EYE,  EAR,  NOSE,  AND  THROAT.  13 

Jackson  on  the"^r~ 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases 
of  the  Eye.  By  Edward  Jackson,  A.M.,  M.D.,  Professor  of 
Ophthalmology,  University  of  Colorado.  i2mo  of  615  pages, 
with  184  illustrations.     Cloth,  ^2.50  net. 

THE    NEW  (2d)    EDITION 
The  Medical  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evi- 
dence of  the  author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo  '  is 
an  appropriate  one  to  apply  to  this  work.  It  will  prove  of  value  to  all  who  are  interested  in 
this  branch  of  medicine." 


rriedrich  and  Curtis  on 
Nose,  Larynx,  and  Ear 


Rhinology,  Laryngology,  and  Otology,  and  Their  Sig- 
nificance in  General  Medicine.  By  Dr.  E.  P.  Friedrich,  of 
Leipzig.  Edited,  with  additions,  by  H.  Holbrook  Curtis,  M.D., 
Consulting  Surgeon  to  the  New  York  Nose  and  Throat  Hospital. 
Octavo  volume  of  350  pages.     Cloth,  ^2.50  net. 


Grant  on  the  Face,  Mouth,  and  Jaws 


A  Text=Book  of  the  Surgical  Principles  and  Surgical 
Diseases  of  the  Face,  Mouth,  and  Jaws.  For  Dental 
Students.  By  H.  Horace  Grant,  A.M.,  M.D.,  Professor  of 
Surgery  and  of  Clinical  Surgery,  Hospital  College  of  Medicine, 
Louisville.  Octavo  of  231  pages,  with  68  illustrations.  Cloth, 
^2.50  net. 


/4  SAUA^DERS'    BOOKS   ON 

Ogden  on  the  Urine 

Clinical  Examination  of  Urine  and  Urinary  Diagnosis. 

A  Clinical  Guide  for  the  Use  of  Practitioners  and  Students  of 
Medicine  and  Surgery.  By  J.  Bergen  Ogden,  M.  D.,  Medical 
Chemist  to  the  Metropolitan  Life  Insurance  Company,  New 
York.  Octavo,  418  pages,  54  text-illustrations,  and  a  number 
of  colored  plates.     Cloth,  ^3.00  net. 

THE  NEW  (3d)   EDITION 

In  t^is  edition  the  work  has  been  brought  absolutely  down  to  the  present 
day.  Urinary  examinations  for  purposes  of  life  insurance  have  been  incor- 
porated, because  a  large  number  of  practitioners  are  often  called  upon  to  make 
such  analyses.  Special  attention  has  been  paid  to  diagnosis  by  the  character 
of  the  urine,  the  diagnosis  of  diseases  of  the  kidneys  and  urinary  passages. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Vecki's  Sexual  Impotence 


The  Pathology  and  Treatment  of    Sexual  Impotence. 

By  Victor  G.  Vecki,  M.  D.     From  the   Second  Revised  and 
Enlarged  German  Edition.      i2mo  volume  of  400  pages. 

THE  NEW  (4th)  EDITION— PREPARING 

This  volume  will  come  to  many  as  a  revelation  of  the  possibilities  of  thera- 
peutics in  this  important  field.  The  whole  subject  of  sexual  impotence  and 
its  treatment  is  discussed  by  the  author  in  an  exhaustive  and  thoroughly  sci- 
entific manner.  In  this  edition  the  boolc  has  been  thoroughly  revised,  and 
new  matter  has  been  added,  especially  to  the  portion  dealing  with  treatment. 

Johns  Hopkins  Hospital  Bulletin 

"A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The  treatment 
of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and  judicious." 


CHEMISTRY,  SKIN,  AND   VENEREAL  DISEASES. 


American  Pocket  Dictionary         New  (7thf EdWon 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A. 
Newman  Borland,  M.D.  Containing  the  definition  of  the  princij^al 
words  used  in  medicine  and  kindred  sciences.  6lo  pages.  Flexible 
leather,  with  gold  edges,' ^i.oo  net;  with  thumb  index,  ^1.25  net. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior. 
lean  recommend  it  to  our  students  without  reserve."— James  W.  Holland,  M.  D., 
Professor  of  Medical  Chefiiistry  and  Toxicology  at  the  fefferson  Medical  College, 
Philadelphia. 

Stel wagon's  Essentials  of  Skin      New  (7th)  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.  D.,  Ph.  D..  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Post-octavo  of  292  pages,  with  72  text-illustra- 
tions and  8  plates.  Cloth,  JJi.oo  net.  In  Saunders'  Question- Compend 
Series. 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been 
noted." —  The  Medical  News. 

Wolffs  Medical  Chemistry  seventh  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiology, 
Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Lawrence 
Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson  Medical 
College.  Revised  by  A.  Ferree  Witmer,  Ph.G.,  M.  D.,  formerly  As- 
sistant Demonstrator  of  Physiology,  University  of  Pennsylvania.  Post- 
octavo  of  225  pages.  Cloth,  ^i.oo  net.  In  Saunders'  Question- Compend 
Series. 

"  The  author's  careful  and  well-studied  selection  of  the  necessary  requirements  of 
the  student  has  enabled  him  to  furnish  a  valuable  aid  to  the  student." — JVem  York 
Medical  fournal. 

Martin's  Minor  Surgery,  Bandaging,  and  the 

Venereal    Diseases  second  Edition.  Revised 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal  Dis- 
eases. By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clinical  Sur- 
gery, University  of  Pennsylvania,  etc.  Post-octavo,  166  pages,  with  78 
illustrations.     Cloth,  ^l.oo  net.     In  Saunders''  Question  Compends. 

"  The  best  condensation  of  the  subjects  of  which  it  treats  yet  placed  before  the  pro 
fession." — The  Medical  News. 

Stevenson's  Photoscopy 

Photoscopy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Steven- 
son, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital.  i2mo  of 
200  pages  ;  illustrated.  Cloth,  ^1.25  net. 

"  It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emer- 
gent pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better 
than  any  previous  account." — Edward  Jackson,  M.  D.,  University  0/  Colorado. 


l6  URINE,  EYE,  EAR,  NOSE,  AND    THROAT. 

Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and  Urine- 
examination.  By  Charles  G.  L.  Wolf,  M.  D.,  Instructor  in  Physi- 
ologic Chemistry,  Cornell  University  Medical  College,  New  York  i2mo 
volume  of  204  pages,  fully  illustrated.     Cloth,  ^1.25  net. 

"The  methods  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book  some  extensive  tables  drawn  up  to  assist  in  urinary  diagnosis." — 
British  Medical  Journal. 

Jackson's  Essentials  of  Eye       Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  By 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of  the 
Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illustrations. 
Cloth,  ^i.oo  net.      In  Saunders    Question- Co7npetid  Series. 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." — Johns  Hopkins  Hospital  Bulletin. 

Gleason's  Nose  and  Throat      Fourth  Edition,  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical 
College,  Philadelphia,  etc.  Post-octavo,  241  pages,  112  illustrations. 
Cloth,  $1.00  net.     In  Saunders''  Quesiio7t-Co?Hpend  Series. 

"  The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." — The  Lancet,  London. 

^,  .     «..  If    .  t_       ¥r^  Third  Edition, 

Gleason  s  Diseases  oi  the  li^ar  Revised 

Essentials  of  Diseases  of  the  Ear.  By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College,  Phila- 
delphia, etc.  Post-octavo  volume  of  214  pages,  with  I14  illustrations. 
Cloth,  ^l.oo  net.     In  Saunders'  Question- Compend  Series. 

"  We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  inhrmntion."— Bristol  Medico-Chirurgical 
Journal. 

Wilcox  on  Genito-Urinary  and  Venereal  Dis- 
eases Ikervi  (2d)  Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Uiinary  Diseases  and 
Syphilology,  Starling-Ohio  Medical  College,  Columbus,  Ohio.  l2mo  of 
321  pages, illustrated.    Cloth,  ^i. 00  net.   In  Saunders'  Question-Compends. 

deSchweinitz    and    Holloway    on    Pulsating 
Exophthalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  $2.00  net. 

"  The  book  deals  very  thoroughly  with  the  whole  subject,  and  in  it  the  most  com- 
plete account  of  the  disease  will  be  found."— 5>-/^?Vj  Medical  Journal. 


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